Provider Demographics
NPI:1518964493
Name:INDIANAPOLIS GASTROENTEROLOGY, LLC
Entity Type:Organization
Organization Name:INDIANAPOLIS GASTROENTEROLOGY, LLC
Other - Org Name:INDIANAPOLIS GASTROENTEROLOGY AND HEPATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:317-865-2955
Mailing Address - Street 1:8051 S EMERSON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8632
Mailing Address - Country:US
Mailing Address - Phone:317-865-2955
Mailing Address - Fax:317-865-2944
Practice Address - Street 1:8051 S EMERSON AVE STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8632
Practice Address - Country:US
Practice Address - Phone:317-865-2955
Practice Address - Fax:317-865-2944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207RG0100X, 207ZP0102X, 363A00000X, 207RI0008X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100058600AMedicaid
IN100058600AMedicaid
IN#066980Medicare PIN
IN100058600Medicaid