Provider Demographics
NPI:1639358641
Name:M. D. HEALTHCARE, LLC
Entity Type:Organization
Organization Name:M. D. HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:STINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-610-3003
Mailing Address - Street 1:6920 PARKDALE PL
Mailing Address - Street 2:SUITE 208
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5612
Mailing Address - Country:US
Mailing Address - Phone:317-610-3003
Mailing Address - Fax:317-610-3005
Practice Address - Street 1:6920 PARKDALE PL
Practice Address - Street 2:SUITE 208
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5612
Practice Address - Country:US
Practice Address - Phone:317-610-3003
Practice Address - Fax:317-610-3005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030274A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100330510BMedicaid
IN1316942303OtherINDIVIDUAL NPI
IN229510AOtherINDIVIDUAL MEDICARE PIN
IN1316942303OtherINDIVIDUAL NPI
IN100330510BMedicaid