Provider Demographics
NPI:1669708756
Name:INDIANA EXCEPTIONAL MEDICAL CARE
Entity type:Organization
Organization Name:INDIANA EXCEPTIONAL MEDICAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMANAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-402-4645
Mailing Address - Street 1:4972 LINCOLN AVE
Mailing Address - Street 2:STE #101
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-7909
Mailing Address - Country:US
Mailing Address - Phone:812-402-3700
Mailing Address - Fax:812-402-4611
Practice Address - Street 1:4972 LINCOLN AVE
Practice Address - Street 2:STE #101
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-7909
Practice Address - Country:US
Practice Address - Phone:812-402-3700
Practice Address - Fax:812-402-4611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
IN01061287A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043282627OtherINDIVIDUAL NPI
IN200807410AMedicaid
IN200807410AMedicaid