Provider Demographics
NPI:1609890672
Name:PHELAN, CYNTHIA M (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:M
Last Name:PHELAN
Suffix:
Gender:F
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:PO BOX 1690
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-1690
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:
Practice Address - Street 1:1300 STATE ST
Practice Address - Street 2:SUITE 2E
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3185
Practice Address - Country:US
Practice Address - Phone:219-326-5700
Practice Address - Fax:219-326-8131
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061246A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000379262OtherANTHEM, BCBS
IN200284520Medicaid
IN200284520Medicaid
IN151020XXMedicare PIN