Healthcare Provider Details

I. General information

NPI: 1043245251
Provider Name (Legal Business Name): SUSAN K. MCILWAIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N. UNIVERSITY BLVD UH 3005
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

950 N MERIDIAN STREET SUITE 500, PROVIDER ENROLLMENT
INDIANAPOLIS IN
46204-3908
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-2167
  • Fax: 317-944-2305
Mailing address:
  • Phone: 317-962-4942
  • Fax: 317-962-4950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71000385A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71000385A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: