Healthcare Provider Details

I. General information

NPI: 1376668780
Provider Name (Legal Business Name): AMERICAN HEALTH NETWORK OF INDIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6820 PARKDALE PL SUITE 105
INDIANAPOLIS IN
46254-6601
US

IV. Provider business mailing address

4850 CENTURY PLAZA RD SUITE 180
INDIANAPOLIS IN
46254-5476
US

V. Phone/Fax

Practice location:
  • Phone: 317-328-6730
  • Fax: 317-388-8457
Mailing address:
  • Phone: 317-328-6730
  • Fax: 317-388-8457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State

VIII. Authorized Official

Name: BEN H PARK
Title or Position: PRESIDENT AND CEO
Credential: MD
Phone: 317-580-6314