Provider Demographics
NPI:1760432397
Name:GUSIC, MARYELLEN E (MD)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:E
Last Name:GUSIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 N MERIDIAN STREET
Mailing Address - Street 2:SUITE 500 - PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-3908
Mailing Address - Country:US
Mailing Address - Phone:317-963-0595
Mailing Address - Fax:317-962-4950
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:SUITE 1300
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-2801
Practice Address - Fax:317-944-5630
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD053599L208000000X
IN01069711A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014850040010Medicaid
IN201055470Medicaid
IN201055470Medicaid
IN068010015Medicare PIN
F68973Medicare UPIN