Provider Demographics
NPI:1942290143
Name:OBSTETRICS & GYNECOLOGY OF INDIANA, LLC
Entity Type:Organization
Organization Name:OBSTETRICS & GYNECOLOGY OF INDIANA, LLC
Other - Org Name:OBSTETRICS & GYNECOLOGY OF INDIANA, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:GATES
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:317-415-1000
Mailing Address - Street 1:1373 RELIABLE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:317-575-7304
Mailing Address - Fax:317-575-7333
Practice Address - Street 1:11595 N MERIDIAN ST
Practice Address - Street 2:SUITE 375
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-6947
Practice Address - Country:US
Practice Address - Phone:317-575-7304
Practice Address - Fax:317-575-7333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50003837A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100218870Medicaid
INCA5229Medicare PIN
677690Medicare PIN