Provider Demographics
NPI:1881694990
Name:LEVINE, JOHN ORELL (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ORELL
Last Name:LEVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:765-747-4236
Mailing Address - Fax:
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:765-747-4236
Practice Address - Fax:765-741-2961
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047772207Q00000X
IL036157490207P00000X, 207Q00000X
IN01047772A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000082847OtherBCBS
10339OtherPHP
IN200153850AMedicaid
080128017OtherRR MEDICARE
IN200153850Medicaid
10339OtherPHP
G67794Medicare UPIN
IN200153850Medicaid
IN862280YMedicare PIN