Provider Demographics
NPI:1114105517
Name:CENTRAL INDIANA PHYSICIAN ALLIANCE, LLC
Entity Type:Organization
Organization Name:CENTRAL INDIANA PHYSICIAN ALLIANCE, LLC
Other - Org Name:IU HEALTH TIPTON PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERBROOKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-278-3505
Mailing Address - Street 1:340 W 10TH ST
Mailing Address - Street 2:FS 5100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3082
Mailing Address - Country:US
Mailing Address - Phone:317-278-3505
Mailing Address - Fax:317-278-3502
Practice Address - Street 1:1000 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072-9753
Practice Address - Country:US
Practice Address - Phone:765-675-1745
Practice Address - Fax:765-675-8257
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDIANA UNIVERSITY HEALTH CARE ASSOCIATES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-07
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000570072OtherANTHEM
IN200900360Medicaid
IN200900360Medicaid