Provider Demographics
NPI:1093760951
Name:HEDGEHOG PSYCHIATRIC
Entity Type:Organization
Organization Name:HEDGEHOG PSYCHIATRIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PENNI
Authorized Official - Middle Name:
Authorized Official - Last Name:FUQUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-337-9967
Mailing Address - Street 1:8563 ZIONSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-1511
Mailing Address - Country:US
Mailing Address - Phone:317-337-9967
Mailing Address - Fax:317-337-9968
Practice Address - Street 1:8563 ZIONSVILLE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1511
Practice Address - Country:US
Practice Address - Phone:317-337-9967
Practice Address - Fax:317-337-9968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003324A1041C0700X
IN70000131A364S00000X
IN71000401A364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN215620Medicare ID - Type UnspecifiedMEDICARE GROUP
IN215610Medicare ID - Type UnspecifiedMEDICARE GROUP