Healthcare Provider Details

I. General information

NPI: 1700249059
Provider Name (Legal Business Name): PREVMED PODIATRY GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 WINDHORST WAY STE 120
GREENWOOD IN
46143-8800
US

IV. Provider business mailing address

1499 WINDHORST WAY STE 120
GREENWOOD IN
46143-8800
US

V. Phone/Fax

Practice location:
  • Phone: 317-886-6639
  • Fax: 888-547-0377
Mailing address:
  • Phone: 317-886-6639
  • Fax: 888-547-0377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000570A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: CLAUDIA JACKSON
Title or Position: VICE PRESIDENT OF FINANCE
Credential:
Phone: 317-522-2054