Provider Demographics
NPI:1467573063
Name:CIRCLE CITY MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:CIRCLE CITY MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-298-0000
Mailing Address - Street 1:3850 SHORE DR
Mailing Address - Street 2:SUITE 113
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5621
Mailing Address - Country:US
Mailing Address - Phone:317-298-0000
Mailing Address - Fax:317-398-0011
Practice Address - Street 1:3850 SHORE DR
Practice Address - Street 2:SUITE 113
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5621
Practice Address - Country:US
Practice Address - Phone:317-298-0000
Practice Address - Fax:317-398-0011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC03242Medicare UPIN
INC03251Medicare UPIN
IN132830Medicare ID - Type UnspecifiedMEDICARD PROVIDER #