Provider Demographics
NPI:1164491759
Name:PICKERILL, CASEY L (MD)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:L
Last Name:PICKERILL
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:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:2525 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3028
Practice Address - Country:US
Practice Address - Phone:765-807-2320
Practice Address - Fax:765-807-2330
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046327A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000337599OtherANTHEM PROVIDER NUMBER
IN200133970AMedicaid
IN000000337599OtherANTHEM PROVIDER NUMBER
ING19175Medicare UPIN
IN200133970AMedicaid