Individual
DR. EDWIN BOEDIONO LIEM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
4023 REAS LN, NEW ALBANY, IN 47150-2228
(812) 206-7660
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
01066649A
IN
207L00000X
Anesthesiology Physician
36354
KY
207L00000X
Anesthesiology Physician
ME170722
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000640496
ANTHEM
IN
01
—
111870
SIHO
IN
05
—
200366540
—
IN
01
—
50027044
PASSPORT ADVANTAGE
IN
05
—
64041981
—
KY
01
—
P00819295
RAILROAD MEDICARE
IN
Enumeration date
05/17/2006
Last updated
03/03/2025
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