1104877745 NPI number — ANESTHESIOLOGY OF INDIANAPOLIS, PC

Table of content: (NPI 1104877745)

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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