Healthcare Provider Details

I. General information

NPI: 1639084759
Provider Name (Legal Business Name): MATTHEW CONRAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1081 BROAD RIPPLE AVE
INDIANAPOLIS IN
46220-2034
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 317-808-0350
  • Fax: 317-808-0349
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36003917A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: