Provider Demographics
NPI:1457959132
Name:INDY ADVANCE THERAPEUTICS, LLC
Entity Type:Organization
Organization Name:INDY ADVANCE THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:
Authorized Official - First Name:JERAD
Authorized Official - Middle Name:
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:317-818-9000
Mailing Address - Street 1:3539 BRUMLEY WAY
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-3017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9245 N MERIDIAN ST STE 225
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1812
Practice Address - Country:US
Practice Address - Phone:317-818-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty