Healthcare Provider Details

I. General information

NPI: 1184860512
Provider Name (Legal Business Name): INDIANA PHYSICIAN SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 E US HIGHWAY 6
VALPARAISO IN
46383-8947
US

IV. Provider business mailing address

5665 NEW NORTHSIDE DR NW SUITE 320
ATLANTA GA
30328-5831
US

V. Phone/Fax

Practice location:
  • Phone: 219-983-8300
  • Fax:
Mailing address:
  • Phone: 770-784-5408
  • Fax: 770-784-5433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRISTOPHER BRIAN DURHAM
Title or Position: PRESIDENT
Credential:
Phone: 770-874-5400