Provider Demographics
NPI:1003871690
Name:PRINCE, ROBERT I (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:I
Last Name:PRINCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8805 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2760
Mailing Address - Country:US
Mailing Address - Phone:317-706-7246
Mailing Address - Fax:317-706-3419
Practice Address - Street 1:533 E COUNTY LINE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1073
Practice Address - Country:US
Practice Address - Phone:317-706-7246
Practice Address - Fax:317-706-3419
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234699208VP0000X
IN01068883A207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010209919Medicaid
IN200999780Medicaid
IL504240OtherMEDICARE GROUP #
IL504240OtherMEDICARE GROUP #
VA006733R79Medicare PIN
IN200999780Medicaid
VA010209919Medicaid