Healthcare Provider Details

I. General information

NPI: 1154392322
Provider Name (Legal Business Name): EMILY A BACKER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 11/27/2023
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 E SOUTHWAY BLVD
KOKOMO IN
46902-3814
US

IV. Provider business mailing address

6626 E. 75TH ST SUITE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 765-865-3300
  • Fax: 765-865-3306
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01045272
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: