Healthcare Provider Details

I. General information

NPI: 1356600118
Provider Name (Legal Business Name): BENJAMIN ETHAN MCALLISTER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 10/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W MCKENZIE RD STE F
GREENFIELD IN
46140-1072
US

IV. Provider business mailing address

1 MEMORIAL SQ STE 50
GREENFIELD IN
46140-1357
US

V. Phone/Fax

Practice location:
  • Phone: 317-468-6200
  • Fax: 317-468-6201
Mailing address:
  • Phone: 317-468-6257
  • Fax: 317-468-6268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number02004445A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: