Healthcare Provider Details

I. General information

NPI: 1154541795
Provider Name (Legal Business Name): INDIANAPOLIS IMMUNIZATION GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 E 86TH ST SUITE E
INDIANAPOLIS IN
46240-1866
US

IV. Provider business mailing address

1030 E 86TH ST SUITE E
INDIANAPOLIS IN
46240-1866
US

V. Phone/Fax

Practice location:
  • Phone: 317-844-2990
  • Fax: 317-844-1706
Mailing address:
  • Phone: 317-844-2990
  • Fax: 317-844-1706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL DURS
Title or Position: PRESIDENT
Credential:
Phone: 317-844-2990