Healthcare Provider Details

I. General information

NPI: 1750380002
Provider Name (Legal Business Name): STEPHEN M PESKOE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 09/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8075 N SHADELAND AVE SUITE 200
INDIANAPOLIS IN
46250-2693
US

IV. Provider business mailing address

920 N SHADELAND AVE SUITE G1
INDIANAPOLIS IN
46219-4898
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-8500
  • Fax: 317-621-8501
Mailing address:
  • Phone: 317-355-9777
  • Fax: 317-355-9760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01025113A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: