Provider Demographics
NPI:1538256920
Name:KALLMYER, PENNY ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:PENNY
Middle Name:ELIZABETH
Last Name:KALLMYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6640 PARKDALE PLACE
Mailing Address - Street 2:SUITE U
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-4698
Mailing Address - Country:US
Mailing Address - Phone:317-291-5190
Mailing Address - Fax:317-291-1510
Practice Address - Street 1:6640 PARKDALE PLACE
Practice Address - Street 2:SUITE U
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-4698
Practice Address - Country:US
Practice Address - Phone:317-291-5190
Practice Address - Fax:317-291-1510
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01041481A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200010530Medicaid
000000093913OtherANTHEM
000000093913OtherANTHEM