Basic Information
Provider Information | |||||||||
NPI: | 1003013673 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KRETCHMAN | ||||||||
FirstName: | ERICA | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WESTLEY | ||||||||
OtherFirstName: | ERICA | ||||||||
OtherMiddleName: | MICHELLE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1100 REID PKWY | ||||||||
Address2: | MEDICAL STAFF SERVICES | ||||||||
City: | RICHMOND | ||||||||
State: | IN | ||||||||
PostalCode: | 473741157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7659833217 | ||||||||
FaxNumber: | 7659833219 | ||||||||
Practice Location | |||||||||
Address1: | 1050 REID PKWY | ||||||||
Address2: | SUITE 300 | ||||||||
City: | RICHMOND | ||||||||
State: | IN | ||||||||
PostalCode: | 473741155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7659358941 | ||||||||
FaxNumber: | 7659358578 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2007 | ||||||||
LastUpdateDate: | 07/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 02004002A | IN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
ID | Type | State | Issuer | Description | 000000774723 | 01 |   | ANTHEM BCBS | OTHER | 0070092 | 05 | OH |   | MEDICAID | 201076370 | 05 | IN |   | MEDICAID |