Provider Demographics
NPI:1588647457
Name:IRICK, ROBERT MANFORD (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MANFORD
Last Name:IRICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10330 N MERIDIAN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 S B ST
Practice Address - Street 2:
Practice Address - City:ELWOOD
Practice Address - State:IN
Practice Address - Zip Code:46036-2081
Practice Address - Country:US
Practice Address - Phone:765-552-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01019073A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A89116Medicare UPIN
IN940240HHHHMedicare PIN