Provider Demographics
NPI:1639109945
Name:EMERGENCY MEDICINE PROFESSIONALS OF INDIANA LLC
Entity Type:Organization
Organization Name:EMERGENCY MEDICINE PROFESSIONALS OF INDIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:MANSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-870-0480
Mailing Address - Street 1:PO BOX 1204
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1204
Mailing Address - Country:US
Mailing Address - Phone:317-802-3160
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:4011 SO MONROE MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-9765
Practice Address - Country:US
Practice Address - Phone:812-824-5700
Practice Address - Fax:812-825-0766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200828620AMedicaid
IN247270Medicare PIN