Provider Demographics
NPI:1255770236
Name:MERIDIAN MEDICAL HEALTH CLINIC, LLC
Entity type:Organization
Organization Name:MERIDIAN MEDICAL HEALTH CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTOINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:TEVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-923-2444
Mailing Address - Street 1:3737 NORTH MERIDIAN STREET
Mailing Address - Street 2:SUITE 410
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4374
Mailing Address - Country:US
Mailing Address - Phone:317-923-2444
Mailing Address - Fax:317-923-8758
Practice Address - Street 1:3737 NORTH MERIDIAN STREET
Practice Address - Street 2:SUITE 410
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4374
Practice Address - Country:US
Practice Address - Phone:317-923-2444
Practice Address - Fax:317-923-8758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-23
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty