=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598776742
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIANA HEALTH CENTERS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2006
-----------------------------------------------------
Last Update Date | 11/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8003 CASTLEWAY DR
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46250-1946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-576-1335
-----------------------------------------------------
Fax | 317-576-1339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8003 CASTLEWAY DR
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46250-1946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-576-1335
-----------------------------------------------------
Fax | 317-576-1339
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | TRACY NAGEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-576-1335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 100223780
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 200443050
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 200527220
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 01023827A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 200284500A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------