Healthcare Provider Details

I. General information

NPI: 1629304134
Provider Name (Legal Business Name): ICEM-WISHARD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2009
Last Update Date: 10/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W 10TH ST
INDIANAPOLIS IN
46202-2859
US

IV. Provider business mailing address

1050 WISHARD BLVD SUITE R2200
INDIANAPOLIS IN
46202-2872
US

V. Phone/Fax

Practice location:
  • Phone: 317-630-7276
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: LISA BRAUN
Title or Position: ADMINISTRATOR
Credential:
Phone: 317-630-7276