=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386624070
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY R. WOOLDRIDGE MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2006
-----------------------------------------------------
Last Update Date | 10/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 MEMORIAL SQ STE 305
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46140-3308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-462-6662
-----------------------------------------------------
Fax | 317-468-6275
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 129
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46140-0129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-468-6270
-----------------------------------------------------
Fax | 317-468-6268
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 01058321A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 01058321A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 01058321A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------