Basic Information
| Provider Information | |||||||||
| NPI: | 1053362053 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KINSELLA | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 SOUTH DR | ||||||||
| Address2: | FESLER HALL, RM 204 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172740273 | ||||||||
| FaxNumber: | 3175672191 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172740273 | ||||||||
| FaxNumber: | 3175672191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2006 | ||||||||
| LastUpdateDate: | 12/15/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01035307 | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100377890 | 05 | IN | MEDICAID |