MEDICARE: DR. JAMIE S STREET MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	01024994A	IN

General Provider Information

NPI Number	:	1346515368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMIE S STREET MD

Provider Business Mailing Address
First Line	:	4050 WASHINGTON BLVD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-2615
Country	:	US
Telephone Number	:	317-283-8162
Fax Number	:	317-283-3644

Provider Business Practice Location Address
First Line	:	4050 WASHINGTON BLVD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-2615
Country	:	US
Telephone Number	:	317-283-8162
Fax Number	:	317-283-3644

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2012
Last Update Date	:	03/09/2012

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