=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043383680
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE KOLBE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 10/26/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1803 BROAD RIPPLE AVE
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46220-2339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-726-0777
-----------------------------------------------------
Fax | 317-726-0779
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1803 BROAD RIPPLE AVE
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46220-2339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-726-0777
-----------------------------------------------------
Fax | 317-726-0779
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MELANIE MARGIOTTA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 317-726-0777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 01036943
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 01036943
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------