Provider Demographics
NPI:1770045486
Name:PAEK, MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:PAEK
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1633 N CAPITOL AVE STE 301
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1476
Practice Address - Country:US
Practice Address - Phone:317-963-5996
Practice Address - Fax:317-963-5446
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01090255A207R00000X, 207RH0002X
COTL.0007541390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300081235Medicaid
IN1103116543OtherANTHEM PTAN
IN267030321OtherMEDICARE PTAN