Healthcare Provider Details

I. General information

NPI: 1518964493
Provider Name (Legal Business Name): INDIANAPOLIS GASTROENTEROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8051 S EMERSON AVE STE 200
INDIANAPOLIS IN
46237-8632
US

IV. Provider business mailing address

8051 S EMERSON AVE STE 200
INDIANAPOLIS IN
46237-8632
US

V. Phone/Fax

Practice location:
  • Phone: 317-865-2955
  • Fax: 317-865-2944
Mailing address:
  • Phone: 317-865-2955
  • Fax: 317-865-2944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIN

VIII. Authorized Official

Name: CHERYL MICHAEL
Title or Position: PRACTICE ADMINISTRATOR
Credential: RN
Phone: 317-865-2955