Healthcare Provider Details

I. General information

NPI: 1861686826
Provider Name (Legal Business Name): PROFESSIONAL ASSOC. PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 SHORE DR
INDIANAPOLIS IN
46254-2607
US

IV. Provider business mailing address

4141 SHORE DR
INDIANAPOLIS IN
46254-2607
US

V. Phone/Fax

Practice location:
  • Phone: 317-924-8315
  • Fax: 317-329-2006
Mailing address:
  • Phone: 317-924-8315
  • Fax: 317-329-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. REBECCA A GOLDBERG
Title or Position: EXECUTIVE DIRECTOR
Credential: R.N.
Phone: 317-924-8208