Healthcare Provider Details

I. General information

NPI: 1780610089
Provider Name (Legal Business Name): AMERICAN HEALTH NETWORK OF INDIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 01/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 LANDMARK DRIVE SUITE A
LAFAYETTE IN
47905
US

IV. Provider business mailing address

3750 LANDMARK DRIVE SUITE A
LAFAYETTE IN
47905
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-4511
  • Fax: 765-447-8375
Mailing address:
  • Phone: 765-448-4511
  • Fax: 765-447-8375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: BEN H PARK
Title or Position: PRESIDENT AND CEO
Credential: M.D.
Phone: 317-580-6307