Provider Demographics
NPI:1871753442
Name:PEACH MEDICAL LLC
Entity type:Organization
Organization Name:PEACH MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:E
Authorized Official - Last Name:PEACH
Authorized Official - Suffix:JR
Authorized Official - Credentials:CO
Authorized Official - Phone:317-445-1475
Mailing Address - Street 1:501 W 62ND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-4758
Mailing Address - Country:US
Mailing Address - Phone:317-577-8892
Mailing Address - Fax:
Practice Address - Street 1:201 PENNSYLVANIA PKWY
Practice Address - Street 2:#200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280-2301
Practice Address - Country:US
Practice Address - Phone:317-577-8892
Practice Address - Fax:317-577-8892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200312880AMedicaid