Basic Information
| Provider Information | |||||||||
| NPI: | 1124317102 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ESTABROOK | ||||||||
| FirstName: | NEIL | ||||||||
| MiddleName: | CRAINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 W WHITE RIVER BLVD | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473034988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776685621 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 420 N 26TH ST | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479042848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654488000 | ||||||||
| FaxNumber: | 7654487623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2011 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0001X | 01076841A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 000001017968 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | 201101670 | 05 | IN | MEDICAID |