Basic Information
| Provider Information | |||||||||
| NPI: | 1033253216 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | M.S.D. OF WASHINGTON TOWNSHIP | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8550 WOODFIELD CROSSING BLVD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462402478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172053332 | ||||||||
| FaxNumber: | 3172053384 | ||||||||
| Practice Location | |||||||||
| Address1: | 8550 WOODFIELD CROSSING BLVD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462402478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172053332 | ||||||||
| FaxNumber: | 3172053384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 08/13/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LICATA | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF BUSINESS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3172053332 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X | Y | Agencies | Local Education Agency (LEA) |
ID Information
| ID | Type | State | Issuer | Description | 100198400A | 05 | IN | MEDICAID |