Healthcare Provider Details

I. General information

NPI: 1073257291
Provider Name (Legal Business Name): INDIANA PELVIC PAIN SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

985 DORMAN ST
INDIANAPOLIS IN
46202-3570
US

IV. Provider business mailing address

985 DORMAN ST
INDIANAPOLIS IN
46202-3570
US

V. Phone/Fax

Practice location:
  • Phone: 317-288-1763
  • Fax: 816-208-9047
Mailing address:
  • Phone: 317-288-1763
  • Fax: 816-208-9047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: AMY DAWN MEDLEY
Title or Position: VICE PRESIDENT
Credential: DPT
Phone: 812-891-3216