NPIMap

Organization Active NPI

Indyderm LLC

  • Dermatopathology Physician
  • Greenwood, IN
National Provider Identifier
1497105191
Registry record updated Feb 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatopathology PhysicianTaxonomy code 207ND0900X
License
01072313A Issued in IN
Legal business name
INDYDERM LLC
Practice address
521 E County Line Rd Ste E
Greenwood, IN 46143-1066
Phone
(317) 215-0928
Fax
(317) 743-8148
NPI assigned
Jun 14, 2016
Last updated
Feb 19, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 19, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Emily Keller, MDNPI 1790928497
Title
Owner
Phone
(317) 215-0928

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatopathology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207ND0900X 01072313A IN Primary

Addresses

Primary practice location

521 E County Line Rd Ste E
Greenwood, IN 46143-1066

Mailing address

521 E County Line Rd Ste E
Greenwood, IN 46143-1066
Phone (317) 215-0928

Other practice location 1

8936 Southpointe Dr
Suite B2
Indianapolis, IN 46227-7507
Phone (317) 215-0928

Other identifiers 1

IdentifierTypeStateIssuer
08029326MedicaidIN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160810000061 IN Part B Supplier - Clinic/Group Practice 7012201320 Receives reassigned benefits from 2 practitioners
Practice locations: Greenwood, IN

National Provider Directory

National Provider Directory

Locations

8936 Southpointe Dr
Ste B2
Indianapolis, IN 46227
Phone (317) 215-0928

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1465862400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1708300800000",
    "number": "1497105191",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "521 E COUNTY LINE RD STE E",
            "city": "GREENWOOD",
            "state": "IN",
            "postal_code": "461431066",
            "telephone_number": "317-215-0928",
            "fax_number": "317-743-8148"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "521 E COUNTY LINE RD STE E",
            "city": "GREENWOOD",
            "state": "IN",
            "postal_code": "461431066",
            "telephone_number": "317-215-0928",
            "fax_number": "317-743-8148"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "8936 Southpointe Dr",
            "address_2": "Suite B2",
            "address_purpose": "LOCATION",
            "city": "Indianapolis",
            "state": "IN",
            "postal_code": "462277507",
            "country_code": "US",
            "telephone_number": "317-215-0928",
            "fax_number": "317-743-8148",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "INDYDERM LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-06-14",
        "last_updated": "2024-02-19",
        "certification_date": "2022-06-23",
        "status": "A",
        "authorized_official_last_name": "KELLER",
        "authorized_official_first_name": "EMILY",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "317-215-0928",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207ND0900X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology, Dermatopathology",
            "state": "IN",
            "license": "01072313A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "08029326",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Greenwood, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.