Healthcare Provider Details

I. General information

NPI: 1679687503
Provider Name (Legal Business Name): RICHARD L. ROUDEBUSH VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3602 E MICHIGAN ST
INDIANAPOLIS IN
46201-3466
US

IV. Provider business mailing address

12306 BLUE SPRINGS LN
FISHERS IN
46037-4053
US

V. Phone/Fax

Practice location:
  • Phone: 317-988-2623
  • Fax:
Mailing address:
  • Phone: 317-576-9867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number
License Number State

VIII. Authorized Official

Name: MS. NICOLE MADOU
Title or Position: SOCIAL WORKER
Credential: MSW
Phone: 317-988-2623