Provider Demographics
NPI:1265457774
Name:DIAGNOSTIC RHEUMATOLOGY AND RESEARCH, PC
Entity Type:Organization
Organization Name:DIAGNOSTIC RHEUMATOLOGY AND RESEARCH, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:317-859-6364
Mailing Address - Street 1:6447 S EAST ST STE A
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-2119
Mailing Address - Country:US
Mailing Address - Phone:317-859-6364
Mailing Address - Fax:317-859-7537
Practice Address - Street 1:6447 S EAST ST STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-2119
Practice Address - Country:US
Practice Address - Phone:317-859-6364
Practice Address - Fax:317-859-7537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN61026374A1744R1102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744R1102XOther Service ProvidersSpecialistResearch StudyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC5686Medicare PIN
IN214850Medicare PIN