Provider Demographics
NPI:1396816922
Name:MATHISON, BARRY A (MD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:A
Last Name:MATHISON
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:2056 LEBANON RD
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-2143
Practice Address - Country:US
Practice Address - Phone:765-361-9930
Practice Address - Fax:765-361-9931
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038539A208M00000X
IN1038539A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000207927OtherANTHEM ID#
IN100196520Medicaid
INM400059956OtherMEDICARE PROVIDER PTAN
IN000000207927OtherANTHEM ID#
IN150970FMedicare PIN
IN000000207927OtherANTHEM ID#