Provider Demographics
NPI:1043394695
Name:EAST CENTRAL INDIANA PATHOLOGISTS PC
Entity Type:Organization
Organization Name:EAST CENTRAL INDIANA PATHOLOGISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRANAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-747-3428
Mailing Address - Street 1:2401 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-3428
Mailing Address - Country:US
Mailing Address - Phone:765-741-3428
Mailing Address - Fax:765-741-2905
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:765-741-3428
Practice Address - Fax:765-741-2905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046076A207ZC0500X
IN01018004A207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Single Specialty
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000101392OtherBLUE SHIELD GROUP
OH2099554Medicaid
INCN0381Medicare PIN
000000101392OtherBLUE SHIELD GROUP