1104877745 NPI number — ANESTHESIOLOGY OF INDIANAPOLIS, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104877745 NPI number — ANESTHESIOLOGY OF INDIANAPOLIS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANESTHESIOLOGY OF INDIANAPOLIS, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104877745
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6069
Provider Second Line Business Mailing Address:
DEPT 87
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46206-6069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-614-9817
Provider Business Mailing Address Fax Number:
317-614-9655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2605 N LEBANON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46052-1476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-282-7905
Provider Business Practice Location Address Fax Number:
800-731-0751
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STRYCKER
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
317-614-9817

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200420540A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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