Healthcare Provider Details

I. General information

NPI: 1861307340
Provider Name (Legal Business Name): STATE OF INDIANA: INDIANA DEPARTMENT OF CORRECTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 W WASHINGTON ST
INDIANAPOLIS IN
46204
US

IV. Provider business mailing address

302 W WASHINGTON ST
INDIANAPOLIS IN
46204
US

V. Phone/Fax

Practice location:
  • Phone: 317-233-6984
  • Fax:
Mailing address:
  • Phone: 317-233-6984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHERRIE L. OLSON
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 317-698-0093