Healthcare Provider Details

I. General information

NPI: 1265457774
Provider Name (Legal Business Name): DIAGNOSTIC RHEUMATOLOGY AND RESEARCH, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6447 S EAST ST STE A
INDIANAPOLIS IN
46227-2119
US

IV. Provider business mailing address

6447 S EAST ST STE A
INDIANAPOLIS IN
46227-2119
US

V. Phone/Fax

Practice location:
  • Phone: 317-859-6364
  • Fax: 317-859-7537
Mailing address:
  • Phone: 317-859-6364
  • Fax: 317-859-7537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License Number61026374A
License Number StateIN

VIII. Authorized Official

Name: DR. MICHAEL T STACK
Title or Position: OWNER
Credential: MD PHD
Phone: 317-859-6364