Healthcare Provider Details

I. General information

NPI: 1770808362
Provider Name (Legal Business Name): MERIDIAN HEALTH SERVICES CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N TILLOTSON AVE
MUNCIE IN
47304-3987
US

IV. Provider business mailing address

240 N TILLOTSON AVE
MUNCIE IN
47304-3988
US

V. Phone/Fax

Practice location:
  • Phone: 765-288-1928
  • Fax: 765-288-8775
Mailing address:
  • Phone: 765-288-1928
  • Fax: 765-288-8775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number422-0-CMHC
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. KIRK SHAFER
Title or Position: VICE PRESIDENT OF FINANCE
Credential:
Phone: 765-288-1928