=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295185247
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISSA SPINO-KEETON DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2016
-----------------------------------------------------
Last Update Date | 10/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 W 11TH ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46202-4108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-491-6000
-----------------------------------------------------
Fax | 317-491-6534
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 N SHADELAND AVE
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46219-4959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-963-9328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZN0500X
-----------------------------------------------------
Taxonomy Name | Neuropathology Physician
-----------------------------------------------------
License Number | 02008087A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | DR.0071145
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------