=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659406692
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IRELAND HIP & KNEE SURGERY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9302 N MERIDIAN ST SUITE 299
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46260-1873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-816-5611
-----------------------------------------------------
Fax | 317-816-5616
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9302 N MERIDIAN ST SUITE 299
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46260-1873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-816-5611
-----------------------------------------------------
Fax | 317-816-5616
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. JANICE K BOLES
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 317-816-5614
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 01025374A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------