Healthcare Provider Details

I. General information

NPI: 1073940664
Provider Name (Legal Business Name): UNIVERSITY MEDICAL DIAGNOSTIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 06/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 INDIANA AVE APT 138
INDIANAPOLIS IN
46202-3275
US

IV. Provider business mailing address

430 INDIANA AVENUE APT 138
INDIANA IN
46202-3275
US

V. Phone/Fax

Practice location:
  • Phone: 791-920-0750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number11017474A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number11017474A
License Number StateIN

VIII. Authorized Official

Name: DR. SHIVI S SIVA
Title or Position: PGY6
Credential: MD
Phone: 317-671-3034