Healthcare Provider Details

I. General information

NPI: 1720539075
Provider Name (Legal Business Name): INDIANAPOLIS PERIOPERATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13000 E 136TH ST STE. 1100
FISHERS IN
46037-9478
US

IV. Provider business mailing address

13000 E 136TH ST STE. 1100
FISHERS IN
46037-9478
US

V. Phone/Fax

Practice location:
  • Phone: 317-513-0538
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10002130A
License Number StateIN

VIII. Authorized Official

Name: DR. PETER CACCAVALLO
Title or Position: INTERNAL MEDICINE PHYSICIAN
Credential: M.D.
Phone: 317-513-0538