Provider Demographics
NPI:1821281973
Name:CLEARVISTA RECOVERY ASSOCIATES PC
Entity Type:Organization
Organization Name:CLEARVISTA RECOVERY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-621-7390
Mailing Address - Street 1:7250 CLEARVISTA DR
Mailing Address - Street 2:SUITE 327A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-4692
Mailing Address - Country:US
Mailing Address - Phone:317-621-7390
Mailing Address - Fax:317-621-4494
Practice Address - Street 1:7250 CLEARVISTA DR
Practice Address - Street 2:SUITE 327A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4692
Practice Address - Country:US
Practice Address - Phone:317-621-7390
Practice Address - Fax:317-621-4494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028972207R00000X, 207RA0401X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN255760Medicare PIN