Provider Demographics
NPI:1487842860
Name:LONGEVITY INSTITUTE OF INDIANA,P.C.
Entity Type:Organization
Organization Name:LONGEVITY INSTITUTE OF INDIANA,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:J
Authorized Official - Last Name:SUMRALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MA
Authorized Official - Phone:317-574-1677
Mailing Address - Street 1:10291 N MERIDIAN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1076
Mailing Address - Country:US
Mailing Address - Phone:317-574-1677
Mailing Address - Fax:317-574-1688
Practice Address - Street 1:10291 N MERIDIAN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1076
Practice Address - Country:US
Practice Address - Phone:317-574-1677
Practice Address - Fax:317-574-1688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01021582A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000087198OtherANTHEM
IN000000087198OtherANTHEM
IN062680Medicare PIN