Provider Demographics
NPI:1558884148
Name:DOHERTY, ANNA MARY (PA)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:MARY
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:MARY
Other - Last Name:MIHELICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:5210 E THOMPSON RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-2085
Practice Address - Country:US
Practice Address - Phone:317-782-7500
Practice Address - Fax:317-782-7515
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002330A363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300007511Medicaid