=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760834147
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAKI M RIDA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2016
-----------------------------------------------------
Last Update Date | 04/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 W 10TH ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46222-3802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-636-4400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 W ICE LAKE RD
-----------------------------------------------------
City | IRON RIVER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49935-9526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 905-875-4486
-----------------------------------------------------
Fax | 906-265-3098
-----------------------------------------------------
=====================================================
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 | 01089356A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------