=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255549812
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HUBERT FORNALIK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2007
-----------------------------------------------------
Last Update Date | 07/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8111 S EMERSON AVE STE 204
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46237-8601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-528-2555
-----------------------------------------------------
Fax | 317-528-2566
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 781076
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48278-1076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-528-4800
-----------------------------------------------------
Fax | 317-865-1479
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 37108
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 01067752A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | MT181806
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207VX0201X
-----------------------------------------------------
Taxonomy Name | Gynecologic Oncology Physician
-----------------------------------------------------
License Number | 01067752A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------