Healthcare Provider Details

I. General information

NPI: 1639128127
Provider Name (Legal Business Name): JONATHAN AARON FRIDELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-4370
  • Fax: 317-278-3268
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number01056178A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: