Healthcare Provider Details

I. General information

NPI: 1942510623
Provider Name (Legal Business Name): MY MD HOUSECALLS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 04/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9002 N MERIDIAN ST SUITE 209
INDIANAPOLIS IN
46260-5381
US

IV. Provider business mailing address

801 W ANN ARBOR TRL SUITE 200
PLYMOUTH MI
48170-1694
US

V. Phone/Fax

Practice location:
  • Phone: 317-848-4460
  • Fax: 317-848-4493
Mailing address:
  • Phone: 734-414-9990
  • Fax: 775-258-1535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateIN

VIII. Authorized Official

Name: KEVIN R RUARK
Title or Position: MEMBER
Credential:
Phone: 734-414-9990