Provider Demographics
NPI:1073530978
Name:RETRUM, ERIC R (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:R
Last Name:RETRUM
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 1:5901 TECHNOLOGY CENTER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-6013
Mailing Address - Country:US
Mailing Address - Phone:317-328-4777
Mailing Address - Fax:317-715-9965
Practice Address - Street 1:5901 TECHNOLOGY CENTER DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-6013
Practice Address - Country:US
Practice Address - Phone:317-328-4777
Practice Address - Fax:317-715-9965
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010271472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100332650Medicaid
IN100332650Medicaid
A82906Medicare UPIN