Provider Demographics
NPI:1760794762
Name:KRODEL, EMILY ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ELIZABETH
Last Name:KRODEL
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:3001 S CREASY LN STE 100A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5206
Practice Address - Country:US
Practice Address - Phone:765-420-5800
Practice Address - Fax:765-420-5801
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38667207QS0010X
SCLL32728207Q00000X
IN01081039A207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM147140151OtherMEDICARE PTAN
IN300019190Medicaid