Provider Demographics
NPI:1740431576
Name:INDIANA PHYSICIAN MANAGEMENT-NORTHEAST, LLC
Entity Type:Organization
Organization Name:INDIANA PHYSICIAN MANAGEMENT-NORTHEAST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:
Authorized Official - Last Name:BICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-870-6716
Mailing Address - Street 1:4685 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:317-870-6716
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:13861 OLIO RD
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-3487
Practice Address - Country:US
Practice Address - Phone:317-870-6716
Practice Address - Fax:317-870-0499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-10
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200924740Medicaid
IN259240Medicare PIN