Provider Demographics
NPI:1073606935
Name:PODIATRY ASSOCIATES OF INDIANA PC
Entity Type:Organization
Organization Name:PODIATRY ASSOCIATES OF INDIANA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:C
Authorized Official - Last Name:RAYNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:317-297-0661
Mailing Address - Street 1:5471 GEORGETOWN RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5793
Mailing Address - Country:US
Mailing Address - Phone:317-297-0661
Mailing Address - Fax:317-328-6338
Practice Address - Street 1:5471 GEORGETOWN RD
Practice Address - Street 2:SUITE C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5793
Practice Address - Country:US
Practice Address - Phone:317-297-0661
Practice Address - Fax:317-328-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200058250AMedicaid
INCD7693Medicare PIN
IN521880Medicare PIN
IN200058250AMedicaid