Provider Demographics
NPI:1265440499
Name:CRECELIUS, SUE (MD)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:
Last Name:CRECELIUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9998 CROSSPOINT BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3307
Mailing Address - Country:US
Mailing Address - Phone:317-806-8260
Mailing Address - Fax:317-806-8296
Practice Address - Street 1:2314 BONNYCASTLE AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1306
Practice Address - Country:US
Practice Address - Phone:317-579-2150
Practice Address - Fax:317-806-8260
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY324342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200159590Medicaid
WV3810004749Medicaid
FL9097732-00Medicaid
TX175113301Medicaid
KY200159590OtherMANAGED HEALTH SERVICES
KY000000222977OtherANTHEM BLUE FACET
NY02193295Medicaid
OH2564783Medicaid
KY64324346Medicaid
KY1159218Medicaid