Provider Demographics
NPI:1497105191
Name:INDYDERM LLC
Entity Type:Organization
Organization Name:INDYDERM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-215-0928
Mailing Address - Street 1:521 E COUNTY LINE RD STE E
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1066
Mailing Address - Country:US
Mailing Address - Phone:317-215-0928
Mailing Address - Fax:317-743-8148
Practice Address - Street 1:521 E COUNTY LINE RD STE E
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1066
Practice Address - Country:US
Practice Address - Phone:317-215-0928
Practice Address - Fax:317-743-8148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072313A207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN08029326Medicaid
IN08029326Medicaid