Provider Demographics
NPI:1316970585
Name:PROFESSIONAL ASSOCIATES PC
Entity type:Organization
Organization Name:PROFESSIONAL ASSOCIATES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-924-8297
Mailing Address - Street 1:3266 N MERIDIAN ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-5846
Mailing Address - Country:US
Mailing Address - Phone:317-924-8297
Mailing Address - Fax:317-924-8270
Practice Address - Street 1:3266 N MERIDIAN ST
Practice Address - Street 2:SUITE 900
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-5846
Practice Address - Country:US
Practice Address - Phone:317-924-8297
Practice Address - Fax:317-924-8348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207K00000X, 207RP1001X
IN207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC10473OtherRAIL ROAD MEDICARE GROUP
IN100047780Medicaid
IN331630Medicare ID - Type UnspecifiedPULMONARY GROUP MEDICARE