Healthcare Provider Details

I. General information

NPI: 1831266154
Provider Name (Legal Business Name): EDWARD J BASTYR III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 ESKENAZI AVE UNIVERSITY MEDICAL DIAGNOSTIC ASSOCIATES, INC.
INDIANAPOLIS IN
46202-5166
US

IV. Provider business mailing address

250 N SHADELAND AVE. SUITE 130
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-880-5045
  • Fax: 317-880-0414
Mailing address:
  • Phone: 317-823-9357
  • Fax: 317-823-9357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number01044193A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number01044193A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: