Provider Demographics
NPI:1053336297
Name:KOELSCH, MICHAEL G (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:KOELSCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:208 CORWIN LANE
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6612
Practice Address - Country:US
Practice Address - Phone:765-453-8567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049321A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01347724OtherMEDICARE RR PTAN
000000083152OtherBCBS PIN
IN224040199OtherMEDICARE PTAN
770002492OtherRAILROAD MEDICARE PIN
IN200251540AMedicaid
INP01270947OtherRR MEDICARE
INP01347724OtherMEDICARE RR PTAN
IN266180379Medicare PIN
063280FFMedicare PIN
ININ1663033Medicare PIN