=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528666922
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARECONNECTMD MEDICAL GROUP INDIANA PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2020
-----------------------------------------------------
Last Update Date | 10/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9465 COUNSELORS ROW STE 200
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46240-3817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 657-202-5944
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16162 BEACH BLVD STE 100
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92647-3828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-789-9585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GEORGE EDWARD FIELDS III
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 714-552-4123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1800X
-----------------------------------------------------
Taxonomy Name | Corporate Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------