Provider Demographics
NPI:1609806470
Name:HANCOCK PHYSICIAN NETWORK, LLC
Entity type:Organization
Organization Name:HANCOCK PHYSICIAN NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUCKERHEIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-468-6236
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-0129
Mailing Address - Country:US
Mailing Address - Phone:317-468-6270
Mailing Address - Fax:317-468-6268
Practice Address - Street 1:156 W MUSKEGON DR
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-3069
Practice Address - Country:US
Practice Address - Phone:317-468-6260
Practice Address - Fax:317-468-6267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000074A101YP2500X
IN28075482A163W00000X
207Q00000X, 207R00000X, 207RC0200X, 207RG0300X, 207RP1001X, 207V00000X, 208000000X, 2084P0800X
IN01061823A2084P0804X
IN01062448A208600000X
IN01064501A208M00000X
IN01052168A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200311740DMedicaid
IN200841490Medicaid
IN200853260Medicaid
IN01061823AOtherLICENSE NUMBER
IN01061823BOtherCSR NUMBER
IN1982757373OtherNPI NUMBER
IN200311740Medicaid
IN111401698OtherNPI NUMBER
IN1467485003OtherNPI NUMBER
IN1548272289OtherNPI NIMBER
IN000000493483OtherANTHEM PIN NUMBER
IN01062448AOtherLICENSE NUMBER
IN208M00000XOtherHOSPITALIST
IN208M00000XOtherHOSPITALIST
IN1548272289OtherNPI NIMBER
IN01061823BOtherCSR NUMBER
IN1467485003OtherNPI NUMBER
IN205110Medicare PIN
IN01062448AOtherLICENSE NUMBER
IN200841490Medicaid