Provider Demographics
NPI:1790205706
Name:EGAN, KATHERINE BLAIRE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:BLAIRE
Last Name:EGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:BLAIRE
Other - Last Name:KERWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE STE 120
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3045
Practice Address - Country:US
Practice Address - Phone:317-355-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11019435A390200000X
IN01091179A2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300068731Medicaid