Provider Demographics
NPI:1578205548
Name:INDIANA HOME BASED PRIMARY CARE PC
Entity Type:Organization
Organization Name:INDIANA HOME BASED PRIMARY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTINGLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-630-7425
Mailing Address - Street 1:805 N WHITTINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-7101
Mailing Address - Country:US
Mailing Address - Phone:502-630-7425
Mailing Address - Fax:
Practice Address - Street 1:11550 N MERIDIAN ST STE 375-A
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-6956
Practice Address - Country:US
Practice Address - Phone:463-223-5702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-11
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No253Z00000XAgenciesIn Home Supportive Care