Healthcare Provider Details

I. General information

NPI: 1982463600
Provider Name (Legal Business Name): PHYSICIAN PROVIDER SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2024
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N HIGH SCHOOL RD
INDIANAPOLIS IN
46214-3759
US

IV. Provider business mailing address

1 INDIANA SQ STE 2060
INDIANAPOLIS IN
46204-2020
US

V. Phone/Fax

Practice location:
  • Phone: 800-526-6797
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANDRE CREESE
Title or Position: CEO
Credential:
Phone: 317-672-8600