MEDICARE: MR. CARL PRUITT

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	1041C0700X	Clinical Social Worker	34003308A	IN

General Provider Information

NPI Number	:	1942302641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARL PRUITT

Provider Business Mailing Address
First Line	:	PO BOX 55107
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-0107
Country	:	US
Telephone Number	:	317-253-7387
Fax Number	:	317-253-7388

Provider Business Practice Location Address
First Line	:	3016 LAKE SHORE DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-2324
Country	:	US
Telephone Number	:	317-253-7387
Fax Number	:	317-253-7388

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

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	07/08/2007

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