Healthcare Provider Details

I. General information

NPI: 1932981313
Provider Name (Legal Business Name): MERIDIAN GAP CLOSURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2023
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3524 N MERIDIAN ST
INDIANAPOLIS IN
46208-4486
US

IV. Provider business mailing address

3524 N MERIDIAN ST
INDIANAPOLIS IN
46208-4486
US

V. Phone/Fax

Practice location:
  • Phone: 317-925-0653
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. ELSE COLE
Title or Position: CEO
Credential:
Phone: 317-496-7137