Healthcare Provider Details

I. General information

NPI: 1437424686
Provider Name (Legal Business Name): MICHAEL MENG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 VILLAGE DR
PENDLETON IN
46064-8960
US

IV. Provider business mailing address

75 VILLAGE DR
PENDLETON IN
46064-8960
US

V. Phone/Fax

Practice location:
  • Phone: 765-778-0913
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11016716A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01074827A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: