Healthcare Provider Details

I. General information

NPI: 1417284563
Provider Name (Legal Business Name): ICEM-UNIVERSITY-RILEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 W 10TH ST
INDIANAPOLIS IN
46202-3082
US

IV. Provider business mailing address

7138 RELIABLE PKWY
CHICAGO IL
60686-0001
US

V. Phone/Fax

Practice location:
  • Phone: 317-278-3500
  • Fax: 317-870-0499
Mailing address:
  • Phone: 317-472-7318
  • Fax: 317-870-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CAROL KARP
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 317-278-3522