Provider Demographics
NPI:1700150679
Name:PENNY W. KALLMYER, M.D., P.C.
Entity Type:Organization
Organization Name:PENNY W. KALLMYER, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:KALLMYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-291-5190
Mailing Address - Street 1:6640 PARKDALE PL
Mailing Address - Street 2:SUITE U
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5619
Mailing Address - Country:US
Mailing Address - Phone:317-291-5190
Mailing Address - Fax:317-291-1510
Practice Address - Street 1:6640 PARKDALE PL
Practice Address - Street 2:SUITE U
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5619
Practice Address - Country:US
Practice Address - Phone:317-291-5190
Practice Address - Fax:317-291-1510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041481208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200010530BMedicaid
INF96836Medicare UPIN