Provider Demographics
NPI:1912010067
Name:SHROUT, DEREK MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:MICHAEL
Last Name:SHROUT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14555B HAZEL DELL PKWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-9805
Mailing Address - Country:US
Mailing Address - Phone:317-817-9355
Mailing Address - Fax:317-817-9356
Practice Address - Street 1:14555B HAZEL DELL PKWY
Practice Address - Street 2:SUITE 130
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46033-9805
Practice Address - Country:US
Practice Address - Phone:317-817-9355
Practice Address - Fax:317-817-9356
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002277A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN248980AMedicare PIN
INV11915Medicare UPIN
IN254250AMedicare PIN