Provider Demographics
NPI:1053530006
Name:KNODERER, HOLLY M (MD)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:M
Last Name:KNODERER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:M
Other - Last Name:TALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:705 RILEY HOSPITAL DRIVE
Practice Address - Street 2:ROC 4340
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-5611
Practice Address - Fax:317-944-3107
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010635052080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200862280Medicaid
INM400031711Medicare PIN