Provider Demographics
NPI:1952354623
Name:LIEM, EDWIN BOEDIONO (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:BOEDIONO
Last Name:LIEM
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:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1850 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4990
Practice Address - Country:US
Practice Address - Phone:502-625-5584
Practice Address - Fax:502-426-2264
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36354207L00000X
IN01066649A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64041981Medicaid
INP00819295OtherRAILROAD MEDICARE
IN000000640496OtherANTHEM
IN50027044OtherPASSPORT
IN111870OtherSIHO
IN50027044OtherPASSPORT ADVANTAGE
IN200366540Medicaid
IN50027044OtherPASSPORT