=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770959520
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERMATOLOGY ASSOCIATES OF INDY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2015
-----------------------------------------------------
Last Update Date | 08/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 W SMITH VALLEY RD STE. B
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46142-1599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-492-6333
-----------------------------------------------------
Fax | 918-493-9405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6966 S UTICA AVE STE. 225
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74136-3903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-492-6333
-----------------------------------------------------
Fax | 918-493-9405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | ROBERT NEVIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 855-492-6333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------