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NPI Code Detail

MEDICARE: EDP OF INDIANA, PC

MEDICARE: EDP OF INDIANA, PC
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
1261QD0000XDental Clinic/Center

General Provider Information

NPI Number : 1548776685
Entity Type Code : Organization
Provider Name (Legal Business Name) : EDP OF INDIANA, PC
Provider Business Mailing Address
First Line : 141 W JACKSON BLVD STE 210
Second Line :
City : CHICAGO
State : IL
Zip : 60604-3048
Country : US
Telephone Number : 312-937-3619
Fax Number :
Provider Business Practice Location Address
First Line : 5470 LAFAYETTE RD
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46254-1620
Country : US
Telephone Number : 317-293-4611
Fax Number :
Authorized Official
Title or Position : DIRECTOR OF INTEGRATION
Name : ROSEANNE BRUNENKANT
Credential :
Telephone Number : 312-937-3619
Provider Enumeration Date : 12/27/2017
Last Update Date : 09/16/2019

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Directions to “EDP OF INDIANA, PC ” Practice Location

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