Healthcare Provider Details

I. General information

NPI: 1376935247
Provider Name (Legal Business Name): THE INDIANA CLINICAL TRIALS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHFIELD DR STE 1240
PLAINFIELD IN
46168-4499
US

IV. Provider business mailing address

1100 SOUTHFIELD DR STE 1240
PLAINFIELD IN
46168-4499
US

V. Phone/Fax

Practice location:
  • Phone: 317-837-6082
  • Fax: 317-837-6080
Mailing address:
  • Phone: 317-837-6082
  • Fax: 317-837-6080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71005371A
License Number StateIN

VII. Legacy identifiers

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

VIII. Authorized Official

Name: SCOTT T GUENTHNER
Title or Position: CEO
Credential: MD
Phone: 317-837-6082