Provider Demographics
NPI:1215192620
Name:MACKE, STEPHANIE M (DO)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:MACKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 MAIN ST STE 110
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-6978
Practice Address - Country:US
Practice Address - Phone:317-957-9150
Practice Address - Fax:317-957-9965
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003599A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01221101OtherRR MEDICARE PTAN
IN200964110Medicaid
IN200964110Medicaid
IN266180225Medicare PIN