Provider Demographics
NPI:1043245251
Name:MCILWAIN, SUSAN K (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:MCILWAIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:950 N MERIDIAN STREET
Mailing Address - Street 2:SUITE 500, PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-3908
Mailing Address - Country:US
Mailing Address - Phone:317-962-4942
Mailing Address - Fax:317-962-4950
Practice Address - Street 1:550 N. UNIVERSITY BLVD
Practice Address - Street 2:UH 3005
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-944-2167
Practice Address - Fax:317-944-2305
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71000385A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00374766OtherRR MCARE
IN200166270Medicaid
INM400060365Medicare PIN
IN200166270Medicaid