NPIMap

Organization Active NPI

Indiana University Health Paoli Inc

Doing business as IU Health Paoli Family and Internal Medicine

  • Rural Health Clinic/Center
  • Paoli, IN
National Provider Identifier
1679182190
Registry record updated Jul 31, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
INDIANA UNIVERSITY HEALTH PAOLI INC
Doing business as
IU Health Paoli Family and Internal Medicine
Practice address
560 W. Longest Street
Paoli, IN 47454-9670
Phone
(812) 723-7440
NPI assigned
Jul 30, 2020
Last updated
Jul 31, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
INDIANA UNIVERSITY HEALTH PAOLI INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 31, 2020

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

Authorized official

Name
Michael L Craig
Title
Cfo
Phone
(812) 353-9171

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

560 W. Longest Street
Paoli, IN 47454-9670

Mailing address

250 N Shadeland Ave
Indianapolis, IN 46219-4959

Other names 1

  • IU Health Paoli Family and Internal Medicine Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200813000878 IN Part A Provider - Rural Health Clinic 2668426016 Practice locations: Paoli, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1679182190. Details of each certification follow.

Rural health clinic certification: CCN 158557

Legal name
INDIANA UNIVERSITY HEALTH PAOLI INC
Doing business as
IU HEALTH PAOLI FAMILY AND INTERNAL MEDICINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 7, 2020
Last certification
Dec 7, 2020
Ownership / control type
2B
Organization structure
OtherNon-profit
Enrollment address
560 W Longest St
Paoli, IN 47454-9670
Related CCNs
151306

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Bloomington Hospital of5 organizations share this tax ID, including this one
Part of
Bloomington Hospital of

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 17

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Corinna Repetto Individual Corporate DirectorBoard of Director Jan 1, 2021
Larry Bailey Individual Corporate OfficerCoo Jan 1, 2022
Skylar E Whiteman Individual Corporate DirectorBoard of Directors Jan 1, 2025
Richard Hendrickson Individual Corporate OfficerTreasurer Oct 1, 2020
Corporate DirectorBoard of Directors Oct 1, 2020
Denzil Ross Individual Corporate OfficerInterim President Feb 22, 2024
Corporate Director Feb 22, 2024
Operational/Managerial Control Feb 22, 2024
Indiana University Health Inc Organization, Indianapolis, IN Corporation, Non-profit Operational/Managerial Control Oct 1, 2020
Joyce Poling Individual Corporate DirectorBoard of Directors Oct 1, 2020
Mohan Shenoy Individual Corporate DirectorBoard of Director Jan 1, 2021
Whitney Aiken Individual Corporate Officer Jan 1, 2026
Julie Minton Individual Corporate DirectorBoard of Directors Oct 1, 2020
Kevin Bernard Gebke Individual Corporate DirectorBoard of Director Aug 16, 2022
Tashera Perry Individual Corporate DirectorBoard of Directors Jan 1, 2025
Paul Quick Individual Corporate DirectorBoard of Directors Jan 1, 2025
Jack Kenworthy Individual Corporate OfficerVice Chairman Oct 1, 2020
Corporate DirectorBoard of Directors Oct 1, 2020
Michael Craig Individual Corporate OfficerCfo Oct 1, 2020
Operational/Managerial Control Oct 1, 2020
Kent N Rodgers Individual Corporate DirectorBoard of Directors Jan 1, 2026
Kamal Girgis Individual Corporate Director Jan 1, 2026

Owners & managing parties with NPI records 26

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

View all 26

Facilities with the same owner 18

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 18

Practitioners & affiliated clinicians

Practitioners 55

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.

View all 55

NPI Registry JSON

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

{
    "created_epoch": "1596067200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1596153600000",
    "number": "1679182190",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "250 N SHADELAND AVE",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462194959"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "560 W. LONGEST STREET",
            "city": "PAOLI",
            "state": "IN",
            "postal_code": "474549670",
            "telephone_number": "812-723-7440"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INDIANA UNIVERSITY HEALTH PAOLI INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "INDIANA UNIVERSITY HEALTH PAOLI INC",
        "enumeration_date": "2020-07-30",
        "last_updated": "2020-07-31",
        "certification_date": "2020-07-31",
        "status": "A",
        "authorized_official_last_name": "CRAIG",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "812-353-9171"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "IU Health Paoli Family and Internal Medicine",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "IU Health Paoli Family and Internal Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Paoli, IN

Sources for this page

Verify at the official NPI Registry.