Provider Demographics
NPI:1639392848
Name:INDIANA UNIVERSITY
Entity Type:Organization
Organization Name:INDIANA UNIVERSITY
Other - Org Name:INDIANAPOLIS EYE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SEELEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-856-7500
Mailing Address - Street 1:501 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3293
Mailing Address - Country:US
Mailing Address - Phone:317-321-1470
Mailing Address - Fax:
Practice Address - Street 1:501 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3293
Practice Address - Country:US
Practice Address - Phone:317-321-1470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200717860AMedicaid