Provider Demographics
NPI:1942481965
Name:ST. MARY ADULT MEDICINE, LLC
Entity Type:Organization
Organization Name:ST. MARY ADULT MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MALAK
Authorized Official - Middle Name:G
Authorized Official - Last Name:HERMINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-293-9039
Mailing Address - Street 1:5525 GEORGETOWN RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-3717
Mailing Address - Country:US
Mailing Address - Phone:317-293-9039
Mailing Address - Fax:317-293-9049
Practice Address - Street 1:5525 GEORGETOWN RD STE F
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-3717
Practice Address - Country:US
Practice Address - Phone:317-293-9039
Practice Address - Fax:317-293-9049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201378550Medicaid
IN56185Medicare UPIN