Basic Information
| Provider Information | |||||||||
| NPI: | 1720347305 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERIDIAN HEALTH SERVICES CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 N TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473043988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | 7657410310 | ||||||||
| Practice Location | |||||||||
| Address1: | 3620 W WHITE RIVER BLVD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473044286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | 7657410310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2012 | ||||||||
| LastUpdateDate: | 07/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | SHAFER | ||||||||
| AuthorizedOfficialFirstName: | KIRK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | C.F.O. | ||||||||
| AuthorizedOfficialTelephone: | 7652881928 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 200978580 | 05 | IN | MEDICAID |