Healthcare Provider Details

I. General information

NPI: 1083184873
Provider Name (Legal Business Name): IMPACT PHYSICIAN GROUP, INDIANA, PULMONARY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W 10TH ST
INDIANAPOLIS IN
46222-3802
US

IV. Provider business mailing address

21 EASTBROOK BND STE 218
PEACHTREE CITY GA
30269-1546
US

V. Phone/Fax

Practice location:
  • Phone: 317-636-4400
  • Fax:
Mailing address:
  • Phone: 678-967-5599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL MILLER
Title or Position: CEO
Credential: CEO
Phone: 678-967-5599