Healthcare Provider Details

I. General information

NPI: 1912132085
Provider Name (Legal Business Name): KENDRICK REGIONAL CENTER FOR COLON AND RECTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 HADLEY RD SUITE 201
MOORESVILLE IN
46158-2905
US

IV. Provider business mailing address

1215 HADLEY RD SUITE 201
MOORESVILLE IN
46158-2905
US

V. Phone/Fax

Practice location:
  • Phone: 317-834-9618
  • Fax: 317-831-9467
Mailing address:
  • Phone: 317-834-9618
  • Fax: 317-831-9467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number01066495A
License Number StateIN

VIII. Authorized Official

Name: CINDY CRUMP
Title or Position: FELLOWSHIP COORDINATOR
Credential:
Phone: 317-834-9618