Provider Demographics
NPI:1215383021
Name:PRACTICE SERVICES OF INDIANA PC
Entity Type:Organization
Organization Name:PRACTICE SERVICES OF INDIANA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GRIFFIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MBA
Authorized Official - Phone:312-600-8484
Mailing Address - Street 1:213 N RACINE AVE
Mailing Address - Street 2:100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1644
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:312-866-8014
Practice Address - Street 1:6401 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-6614
Practice Address - Country:US
Practice Address - Phone:312-733-9730
Practice Address - Fax:312-866-8014
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OAK STREET HEALTH MSO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty