Provider Demographics
NPI:1265455836
Name:PATEL, KISHAN B (MD)
Entity Type:Individual
Prefix:
First Name:KISHAN
Middle Name:B
Last Name:PATEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:253 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1501
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-446-7023
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062245A207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000613586OtherANTHEM PROVIDER PIN / URGENT CARE
IN200828050Medicaid
IN000000485526OtherANTHEM PROVIDER PIN / FAMILY PRACTICE-HOSPITALIST
IN9449511OtherPHCS PID NUMBER
IN815500F5Medicare PIN
INI59510Medicare UPIN
IN921480LLMedicare PIN
IN000000485526OtherANTHEM PROVIDER PIN / FAMILY PRACTICE-HOSPITALIST
IN000000613586OtherANTHEM PROVIDER PIN / URGENT CARE
IN815510IIIMedicare PIN