Provider Demographics
NPI:1265755136
Name:INDIANA STATE DEPARTMENT OF HEALTH
Entity type:Organization
Organization Name:INDIANA STATE DEPARTMENT OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LIXIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, D(ABMM)
Authorized Official - Phone:317-921-8509
Mailing Address - Street 1:550 W 16TH STREET
Mailing Address - Street 2:SUTIE B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-7804
Mailing Address - Country:US
Mailing Address - Phone:317-921-5500
Mailing Address - Fax:317-927-7801
Practice Address - Street 1:550 W 16TH STREET
Practice Address - Street 2:SUTIE B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-7804
Practice Address - Country:US
Practice Address - Phone:317-921-5500
Practice Address - Fax:317-927-7801
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDIANA STATE DEPARTMENT OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-08
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
15D0662599OtherCLIA
IN(LPI):100284680AMedicaid