Provider Demographics
NPI:1689653982
Name:CITIZENS HEALTH CORPORATION
Entity Type:Organization
Organization Name:CITIZENS HEALTH CORPORATION
Other - Org Name:CITIZENS HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-396-0279
Mailing Address - Street 1:1650 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1715
Mailing Address - Country:US
Mailing Address - Phone:317-924-6351
Mailing Address - Fax:317-927-3634
Practice Address - Street 1:1650 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1715
Practice Address - Country:US
Practice Address - Phone:317-924-6351
Practice Address - Fax:317-927-3634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QC1500X
IN50000856A261QF0400X
IN60003640A3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100196020BMedicaid
1524758OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IN100196020AMedicaid
IN100297090AMedicaid
IN151812Medicare Oscar/Certification
IN151837Medicare Oscar/Certification
IN113810Medicare Oscar/Certification