Basic Information
| Provider Information | |||||||||
| NPI: | 1033222633 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLON & RECTAL CARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7430 N SHADELAND AVE | ||||||||
| Address2: | COLON & RECTAL CARE SUITE 200 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178418090 | ||||||||
| FaxNumber: | 3175777538 | ||||||||
| Practice Location | |||||||||
| Address1: | 7430 N SHADELAND AVE | ||||||||
| Address2: | COLON & RECTAL CARE SUITE 200 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178418090 | ||||||||
| FaxNumber: | 3175777538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 05/04/2015 | ||||||||
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| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | SUSIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3178418090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | 50002167A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100236230A | 05 | IN | MEDICAID |