Healthcare Provider Details

I. General information

NPI: 1427092212
Provider Name (Legal Business Name): BRUCE R DURELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6614 CAPTIVA PASS
PLAINFIELD IN
46168-8000
US

IV. Provider business mailing address

6614 CAPTIVA PASS
PLAINFIELD IN
46168-8000
US

V. Phone/Fax

Practice location:
  • Phone: 317-679-0145
  • Fax:
Mailing address:
  • Phone: 317-679-0145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01035248
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number01035248A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01035248A
License Number StateIN

VII. Legacy identifiers

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

# 1
Identifier200103280
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: