MEDICARE: MATTHEW F WACK 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	207RI0200X	Infectious Disease Physician	01047042A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356389928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW F WACK MD

Provider Business Mailing Address
First Line	:	250 N SHADELAND AVE
Second Line	:	SUITE 130
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-4959
Country	:	US
Telephone Number	:	317-587-2300
Fax Number	:	317-587-2342

Provider Business Practice Location Address
First Line	:	1633 N CAPITOL AVE
Second Line	:	SUITE 750
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-1270
Country	:	US
Telephone Number	:	317-962-0953
Fax Number	:	317-962-2455

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

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	01/19/2016

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