Provider Demographics
NPI:1285673616
Name:METHODIST MEDICAL GROUP PHYSICIANS INC
Entity Type:Organization
Organization Name:METHODIST MEDICAL GROUP PHYSICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:POLLOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-962-1773
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-962-4836
Mailing Address - Fax:
Practice Address - Street 1:950 N MERIDIAN ST
Practice Address - Street 2:STE 500
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-1077
Practice Address - Country:US
Practice Address - Phone:317-962-4836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100239170Medicaid
IN200002300Medicaid
IN221900Medicare PIN
IN144060Medicare PIN
IN521070Medicare PIN
IN144020Medicare PIN