Provider Demographics
NPI:1255314936
Name:LOTTICH, SUSAN CHACE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CHACE
Last Name:LOTTICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 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 1:8040 CLEARVISTA PARKWAY
Practice Address - Street 2:SUITE 290
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-5604
Practice Address - Country:US
Practice Address - Phone:317-621-7780
Practice Address - Fax:317-621-7783
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037538A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000681404OtherANTHEM
IN000000780857OtherANTHEM
IN100130980Medicaid
INP01170034OtherRR MEDICARE PTAN
IN000000780857OtherANTHEM
IN266180087Medicare PIN