Provider Demographics
NPI:1114093390
Name:KERESEY, RICHARD ALLAN (PAC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ALLAN
Last Name:KERESEY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4850 W CENTURY PLAZA RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254
Mailing Address - Country:US
Mailing Address - Phone:317-216-2828
Mailing Address - Fax:317-216-2839
Practice Address - Street 1:5603 W RAYMOND
Practice Address - Street 2:SUITE A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-4356
Practice Address - Country:US
Practice Address - Phone:317-241-8266
Practice Address - Fax:317-247-4978
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000012A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant