Healthcare Provider Details

I. General information

NPI: 1104238435
Provider Name (Legal Business Name): TYLER MICHAEL FROMM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2014
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHFIELD DR STE 1220
PLAINFIELD IN
46168-4499
US

IV. Provider business mailing address

1100 SOUTHFIELD DR STE 1220
PLAINFIELD IN
46168-4499
US

V. Phone/Fax

Practice location:
  • Phone: 317-838-3443
  • Fax: 317-838-3444
Mailing address:
  • Phone: 317-554-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01080853A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11017595A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01080853A
License Number StateIN

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: