Basic Information
| Provider Information | |||||||||
| NPI: | 1356389928 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WACK | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175872300 | ||||||||
| FaxNumber: | 3175872342 | ||||||||
| Practice Location | |||||||||
| Address1: | 1633 N CAPITOL AVE | ||||||||
| Address2: | SUITE 750 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179620953 | ||||||||
| FaxNumber: | 3179622455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 01/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 01047042A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 200139350 | 05 | IN | MEDICAID |