Provider Demographics
NPI:1760576490
Name:CENTRAL INDIANA GASTROENTEROLOGY GROUP PC
Entity Type:Organization
Organization Name:CENTRAL INDIANA GASTROENTEROLOGY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-646-8477
Mailing Address - Street 1:2020 MERIDIAN STREET
Mailing Address - Street 2:SUITE 340
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-4349
Mailing Address - Country:US
Mailing Address - Phone:765-646-8477
Mailing Address - Fax:765-649-0014
Practice Address - Street 1:2020 MERIDIAN STREET
Practice Address - Street 2:SUITE 340
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4349
Practice Address - Country:US
Practice Address - Phone:765-646-8477
Practice Address - Fax:765-649-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65936270Medicaid
INCM2269OtherMEDICARE RAILROAD
INCE9088OtherMEDICARE RAILROAD
IN100171370Medicaid
IN249510Medicare PIN