Provider Demographics
NPI:1033167499
Name:MERIDIAN MEDICAL GROUP PC
Entity Type:Organization
Organization Name:MERIDIAN MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-962-5870
Mailing Address - Street 1:1801 N SENATE BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202
Mailing Address - Country:US
Mailing Address - Phone:317-962-6300
Mailing Address - Fax:317-962-2346
Practice Address - Street 1:1115 N RONALD REAGAN PKWY
Practice Address - Street 2:SUITE 347
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123
Practice Address - Country:US
Practice Address - Phone:317-217-2111
Practice Address - Fax:317-217-2110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN050037961261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100380420BMedicaid
INZJ6090Medicare PIN