Provider Demographics
NPI:1508334814
Name:EMERALD NEURO-RECOVER
Entity Type:Organization
Organization Name:EMERALD NEURO-RECOVER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:G
Authorized Official - Last Name:DUNTEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CREDENTIALING DEPT
Authorized Official - Phone:630-770-3800
Mailing Address - Street 1:12265 HANCOCK ST STE 42
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5801
Mailing Address - Country:US
Mailing Address - Phone:317-606-8778
Mailing Address - Fax:317-740-0534
Practice Address - Street 1:12265 HANCOCK ST STE 42
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5801
Practice Address - Country:US
Practice Address - Phone:317-606-8778
Practice Address - Fax:317-740-0534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-05
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200216290Medicaid
OH2617421Medicaid
IN000000380603OtherANTHEM
MI104874712Medicaid