Provider Demographics
NPI:1194033092
Name:STATE OF INDIANA AUDITOR OF STATE
Entity Type:Organization
Organization Name:STATE OF INDIANA AUDITOR OF STATE
Other - Org Name:INDIANA DEPARTMENT OF HEALTH LABORATORIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST CMMR & STATE LAB DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LIXIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, D(ABMM)
Authorized Official - Phone:317-921-5832
Mailing Address - Street 1:550 W 16TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2218
Mailing Address - Country:US
Mailing Address - Phone:317-921-5500
Mailing Address - Fax:317-924-7801
Practice Address - Street 1:550 W 16TH ST STE B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2218
Practice Address - Country:US
Practice Address - Phone:317-921-5500
Practice Address - Fax:317-924-7801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN15D0662599291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100284680AMedicaid
IN100284680Medicaid