Provider Demographics
NPI:1720539075
Name:INDIANAPOLIS PERIOPERATIVE MEDICINE
Entity Type:Organization
Organization Name:INDIANAPOLIS PERIOPERATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERNAL MEDICINE PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:CACCAVALLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-513-0538
Mailing Address - Street 1:13000 E 136TH ST
Mailing Address - Street 2:STE. 1100
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9478
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13000 E 136TH ST
Practice Address - Street 2:STE. 1100
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9478
Practice Address - Country:US
Practice Address - Phone:317-513-0538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002130A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty