Healthcare Provider Details

I. General information

NPI: 1588123541
Provider Name (Legal Business Name): REBECCA LONG HETRICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA GLYNNE LONG

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

PO BOX 778912
CHICAGO IL
60677-8912
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-2172
  • Fax: 317-278-3031
Mailing address:
  • Phone: 317-777-6435
  • Fax: 317-777-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number01088155A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: