Provider Demographics
NPI:1144293150
Name:XIE, PEIGUANG TYLER (MD)
Entity type:Individual
Prefix:
First Name:PEIGUANG
Middle Name:TYLER
Last Name:XIE
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:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE
Practice Address - Street 2:SUITE 375B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3052
Practice Address - Country:US
Practice Address - Phone:317-355-9370
Practice Address - Fax:317-621-5678
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058468A207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200511010Medicaid
INP01214638OtherRR MEDICARE PTAN
INP01148174OtherRR MEDICARE PTAN
INM400015130Medicare PIN
IN200511010Medicaid
INM400069399Medicare PIN
INP01214638OtherRR MEDICARE PTAN
IN266180130Medicare PIN