Provider Demographics
NPI:1689629511
Name:INTEGRATIVE HEALTH SPECIALIST OF INDIANA PC
Entity Type:Organization
Organization Name:INTEGRATIVE HEALTH SPECIALIST OF INDIANA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIDER
Authorized Official - Suffix:
Authorized Official - Credentials:BUSINESS OFFICE
Authorized Official - Phone:317-781-3604
Mailing Address - Street 1:9333 N MERIDIAN ST
Mailing Address - Street 2:STE 202
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1872
Mailing Address - Country:US
Mailing Address - Phone:317-580-9333
Mailing Address - Fax:317-818-8933
Practice Address - Street 1:9333 N MERIDIAN ST
Practice Address - Street 2:STE 202
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1872
Practice Address - Country:US
Practice Address - Phone:317-580-9333
Practice Address - Fax:317-818-8933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1629048715OtherINDIVIDUAL NPI
IN1619947710OtherINDIVIDUAL NPI
IN000000243460OtherANTHEM
IN1558331652OtherINDIVIDUAL NPI
IN223880CMedicare PIN
IN1558331652OtherINDIVIDUAL NPI
IN1619947710OtherINDIVIDUAL NPI
IN1629048715OtherINDIVIDUAL NPI