Provider Demographics
NPI:1417409186
Name:INDIANA HEALTHCARE PHYSICIAN SERVICES, INC
Entity type:Organization
Organization Name:INDIANA HEALTHCARE PHYSICIAN SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.O.O.
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-357-8230
Mailing Address - Street 1:640 KOLTER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3570
Mailing Address - Country:US
Mailing Address - Phone:724-357-7196
Mailing Address - Fax:724-357-7279
Practice Address - Street 1:640 KOLTER DR
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3570
Practice Address - Country:US
Practice Address - Phone:724-357-7196
Practice Address - Fax:724-357-7279
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IHPS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-28
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017702500010Medicaid
PA0017702500010Medicaid