Healthcare Provider Details

I. General information

NPI: 1568699122
Provider Name (Legal Business Name): VERSITI INDIANA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 09/06/2021
Certification Date: 09/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 N MERIDIAN ST
INDIANAPOLIS IN
46208-4437
US

IV. Provider business mailing address

3450 N MERIDIAN ST
INDIANAPOLIS IN
46208-4437
US

V. Phone/Fax

Practice location:
  • Phone: 317-916-5237
  • Fax:
Mailing address:
  • Phone: 317-927-1613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number74465305
License Number StateIN

VIII. Authorized Official

Name: DAWN HENSE
Title or Position: DIRECTOR - ACCOUNTING
Credential:
Phone: 414-937-6387