Provider Demographics
NPI:1346489630
Name:LARGE, MICHAEL CHRISTOPHER (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHRISTOPHER
Last Name:LARGE
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 1:679 E COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1049
Mailing Address - Country:US
Mailing Address - Phone:317-885-1250
Mailing Address - Fax:317-859-4268
Practice Address - Street 1:14300 E 138TH STE A
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-0087
Practice Address - Country:US
Practice Address - Phone:317-813-1660
Practice Address - Fax:317-813-1667
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-049267208800000X
IN01072896A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201191980Medicaid
IN000000826877OtherANTHEM PIN
IN1548340177OtherNAAB ROAD DME NPI
IN100194370OtherGROUP MEDICAID NUMBER
IN1487680518OtherGROUP NPI
IN200288740OtherGROUP MEDICAID NUMBER
IN1548340177OtherNAAB ROAD DME NPI