=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922417476
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVERY HUBBARD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2014
-----------------------------------------------------
Last Update Date | 08/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1481 W 10TH ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46202-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-554-0000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12715 ROAN LN
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46236-5108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-417-9533
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246QM0706X
-----------------------------------------------------
Taxonomy Name | Medical Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------