Healthcare Provider Details

I. General information

NPI: 1417283953
Provider Name (Legal Business Name): MEDIC AZ QUALITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2009
Last Update Date: 10/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11330 KNIGHTSBRIDGE LN
FISHERS IN
46037-9151
US

IV. Provider business mailing address

11330 KNIGHTSBRIDGE LN
FISHERS IN
46037-9151
US

V. Phone/Fax

Practice location:
  • Phone: 317-410-2868
  • Fax: 317-578-3638
Mailing address:
  • Phone: 317-410-2868
  • Fax: 317-578-3638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number05004402A
License Number StateIN

VIII. Authorized Official

Name: GAMAL RAMADAN ELSAYED
Title or Position: MANAGER
Credential: DSC
Phone: 317-410-2858