Provider Demographics
NPI:1720285976
Name:INDIANAPOLIS PERIOPERATIVE MEDICINE, LLC
Entity Type:Organization
Organization Name:INDIANAPOLIS PERIOPERATIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:CACCAVALLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-678-3585
Mailing Address - Street 1:13000 E 136TH ST
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9478
Mailing Address - Country:US
Mailing Address - Phone:317-678-3585
Mailing Address - Fax:317-863-5084
Practice Address - Street 1:13000 E 136TH ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9478
Practice Address - Country:US
Practice Address - Phone:317-678-3585
Practice Address - Fax:317-863-5084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1053181A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200424870-AMedicaid
INDE0272OtherRR MEDICARE GROUP
IN200424870-AMedicaid