Provider Demographics
NPI:1205816832
Name:INDIANA HEART HOSPITAL, LLC
Entity Type:Organization
Organization Name:INDIANA HEART HOSPITAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMACHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-621-8057
Mailing Address - Street 1:6233 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0062
Mailing Address - Country:US
Mailing Address - Phone:317-621-8000
Mailing Address - Fax:317-621-8111
Practice Address - Street 1:8075 N SHADELAND AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2693
Practice Address - Country:US
Practice Address - Phone:317-621-8000
Practice Address - Fax:317-621-8111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN003312282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
7786435OtherAETNA PROVIDER NUMBER
000000251112OtherANTHEM PROVIDER NUMBER
23783HHOtherHEALTHMARK PROVIDER NUMBE
IN200400370AMedicaid
IN200484840AMedicaid
000000020325OtherM PLAN PROVIDER NUMBER
IN200484840AMedicaid