Basic Information
Provider Information | |||||||||
NPI: | 1134129885 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARDIOTHORACIC ANESTHESIA OF INDIANA, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6069 | ||||||||
Address2: | DEPT 18 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462066069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178026290 | ||||||||
FaxNumber: | 3178700499 | ||||||||
Practice Location | |||||||||
Address1: | 2001 W 86TH ST | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462601902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178026290 | ||||||||
FaxNumber: | 3178700499 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2005 | ||||||||
LastUpdateDate: | 09/27/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STOGSDILL | ||||||||
AuthorizedOfficialFirstName: | DONALD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3178026290 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | 50003431 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
ID Information
ID | Type | State | Issuer | Description | 100120820A | 05 | IN |   | MEDICAID |