Healthcare Provider Details

I. General information

NPI: 1033199138
Provider Name (Legal Business Name): DERMATOLOGY CENTER OF INDIANA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHFIELD DR STE 1240
PLAINFIELD IN
46168-4499
US

IV. Provider business mailing address

111 NEW HAMPSHIRE AVE STE 2
PORTSMOUTH NH
03801-2864
US

V. Phone/Fax

Practice location:
  • Phone: 317-838-9911
  • Fax: 317-837-6080
Mailing address:
  • Phone: 802-909-2053
  • Fax: 330-965-9325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number01051020A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7430356
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerAETNA
# 2
Identifier070017306
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerRAILROAD MEDICARE
# 3
Identifier200417550A
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name: SCOTT THOMAS GUENTHNER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 317-838-9911