Provider Demographics
NPI:1588123541
Name:HETRICK, REBECCA LONG (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LONG
Last Name:HETRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:GLYNNE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1120 W MICHIGAN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5209
Mailing Address - Country:US
Mailing Address - Phone:317-278-6425
Mailing Address - Fax:317-968-1484
Practice Address - Street 1:1120 W MICHIGAN ST STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5209
Practice Address - Country:US
Practice Address - Phone:317-278-6425
Practice Address - Fax:317-968-1484
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01088155A2080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program