Provider Demographics
NPI:1851565428
Name:CARVER, MARY MCCALLISTER (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MCCALLISTER
Last Name:CARVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUSAN
Other - Last Name:MCCALLISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7120 CLEARVISTA DRIVE
Practice Address - Street 2:SUITE 2100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-0020
Practice Address - Country:US
Practice Address - Phone:317-621-2740
Practice Address - Fax:317-621-5658
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071765A207R00000X
UT7590715-1205208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201111350Medicaid
INP01214630OtherRR MEDICARE PTAN
INP01247388OtherRR MEDICARE PTAN
IN251320006Medicare PIN
IN201111350Medicaid