1487342671 NPI number — JOSEPHSON WALLACK MUNSHOWER NEUROLOGY PC

Table of content: (NPI 1487342671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487342671 NPI number — JOSEPHSON WALLACK MUNSHOWER NEUROLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSEPHSON WALLACK MUNSHOWER NEUROLOGY 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:
1487342671
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6983 HILLSDALE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250-2054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-849-8350
Provider Business Mailing Address Fax Number:
317-576-6311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 N WABASH AVE STE 470
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46952-2685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-455-8822
Provider Business Practice Location Address Fax Number:
765-865-3935
Provider Enumeration Date:
04/26/2023

Additional Information

Authorized Official

Authorized Official Last Name:
MATTOX
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO/CIO
Authorized Official Telephone Number:
317-308-2828

Provider Taxonomy Codes

  • Taxonomy code: 2084S0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300074758 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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