Provider Demographics
NPI:1740410281
Name:CITIZENS HEALTH / BARTON ANNEX
Entity Type:Organization
Organization Name:CITIZENS HEALTH / BARTON ANNEX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURTRUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:317-396-0280
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:317-927-3098
Practice Address - Street 1:501 N EAST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-1632
Practice Address - Country:US
Practice Address - Phone:317-637-3449
Practice Address - Fax:317-927-3098
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITIZENS HEALTH CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-17
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100196020BMedicaid
IN151837Medicare PIN