Healthcare Provider Details

I. General information

NPI: 1548776685
Provider Name (Legal Business Name): EDP OF INDIANA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2017
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5470 LAFAYETTE RD
INDIANAPOLIS IN
46254-1620
US

IV. Provider business mailing address

141 W JACKSON BLVD STE 210
CHICAGO IL
60604-3048
US

V. Phone/Fax

Practice location:
  • Phone: 317-293-4611
  • Fax:
Mailing address:
  • Phone: 312-937-3619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROSEANNE BRUNENKANT
Title or Position: DIRECTOR OF INTEGRATION
Credential:
Phone: 312-937-3619