Healthcare Provider Details

I. General information

NPI: 1366985046
Provider Name (Legal Business Name): MR. MICHAEL CORYEA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

898 E MAIN ST
GREENWOOD IN
46143
US

IV. Provider business mailing address

898 E MAIN ST
GREENWOOD IN
46143-1407
US

V. Phone/Fax

Practice location:
  • Phone: 317-887-1348
  • Fax:
Mailing address:
  • Phone: 317-887-1348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number28196119A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71006936A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: