Healthcare Provider Details

I. General information

NPI: 1104579770
Provider Name (Legal Business Name): MATTHEW MCCRACKEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8111 S EMERSON AVE FL 5
INDIANAPOLIS IN
46237-8601
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 317-528-6298
  • Fax: 317-528-8532
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71012225A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28157506A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: