=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427795350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRANCISCAN ALLIANCE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2022
-----------------------------------------------------
Last Update Date | 09/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10767 ILLINOIS ST # A1100
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-8972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-528-5801
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | CREDENTIALING SUPERVISOR
-----------------------------------------------------
Name | KATHERINE WILHELM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-528-4262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------