Provider Demographics
NPI:1568410926
Name:MERIDIAN MEDICAL GROUP PC
Entity Type:Organization
Organization Name:MERIDIAN MEDICAL GROUP PC
Other - Org Name:MERIDIAN ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-962-5870
Mailing Address - Street 1:1801 N SENATE BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202
Mailing Address - Country:US
Mailing Address - Phone:317-962-6300
Mailing Address - Fax:317-962-2346
Practice Address - Street 1:1801 N SENATE BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-962-6300
Practice Address - Fax:317-962-2346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006221261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100380920AMedicaid
INZJ0460Medicare PIN