Provider Demographics
NPI:1023464294
Name:CLEANSLATE MEDICAL GROUP OF INDIANA LLC
Entity type:Organization
Organization Name:CLEANSLATE MEDICAL GROUP OF INDIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:SMOLAREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-999-5188
Mailing Address - Street 1:8 CADILLAC DR STE 180
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5393
Mailing Address - Country:US
Mailing Address - Phone:615-425-0220
Mailing Address - Fax:833-279-7074
Practice Address - Street 1:101 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:IN
Practice Address - Zip Code:46001-2017
Practice Address - Country:US
Practice Address - Phone:765-233-0903
Practice Address - Fax:833-279-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-06
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty