Basic Information
| Provider Information | |||||||||
| NPI: | 1043245251 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCILWAIN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N MERIDIAN STREET | ||||||||
| Address2: | SUITE 500, PROVIDER ENROLLMENT | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462043908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179624942 | ||||||||
| FaxNumber: | 3179624950 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 N. UNIVERSITY BLVD | ||||||||
| Address2: | UH 3005 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179442167 | ||||||||
| FaxNumber: | 3179442305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 05/09/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71000385A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 71000385A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | P00374766 | 01 | IN | RR MCARE | OTHER | 200166270 | 05 | IN | MEDICAID |