MEDICARE: MD2U INDIANA LLC

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	261QP2300X	Primary Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	15D2045574	OTHER	IN	CLIA - CERTIFICATE OF WAIVER

General Provider Information

NPI Number	:	1598070740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MD2U INDIANA LLC

Provider Business Mailing Address
First Line	:	PO BOX 7219
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40257-0219
Country	:	US
Telephone Number	:	502-327-9100
Fax Number	:	855-632-8329

Provider Business Practice Location Address
First Line	:	8888 KEYSTONE XING
Second Line	:	SUITE 1300
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-4609
Country	:	US
Telephone Number	:	502-327-9100
Fax Number	:	855-632-8329

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	GREGORY D LATTA
Credential	:
Telephone Number	:	502-327-9100

Provider Enumeration Date	:	08/12/2010
Last Update Date	:	03/02/2015

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Directions to “MD2U INDIANA LLC ” Practice Location

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