Provider Demographics
NPI:1154405645
Name:LEROY, BRENDAN (MD)
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:LEROY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:545 VITALITY DR STE 100A
Practice Address - Street 2:
Practice Address - City:FORTVILLE
Practice Address - State:IN
Practice Address - Zip Code:46040
Practice Address - Country:US
Practice Address - Phone:317-621-9220
Practice Address - Fax:317-621-9222
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062433207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01390900OtherMEDICARE RR PTAN
IN200830820Medicaid
0000000566825OtherINDIANA BCBS/ANTHEM HEALTH
9814091OtherAETNA HEALTH PLANS
INP00637726Medicare PIN
0000000566825OtherINDIANA BCBS/ANTHEM HEALTH
IN257080AMedicare PIN