Basic Information
Provider Information | |||||||||
NPI: | 1225077373 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARMEL AMBULATORY SURGERY CENTER,LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13421 OLD MERIDIAN ST | ||||||||
Address2: |   | ||||||||
City: | CARMEL | ||||||||
State: | IN | ||||||||
PostalCode: | 460321427 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3177061600 | ||||||||
FaxNumber: | 3177061601 | ||||||||
Practice Location | |||||||||
Address1: | 13421 OLD MERIDIAN ST | ||||||||
Address2: |   | ||||||||
City: | CARMEL | ||||||||
State: | IN | ||||||||
PostalCode: | 460321427 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3177061600 | ||||||||
FaxNumber: | 3177061601 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2006 | ||||||||
LastUpdateDate: | 07/15/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BODEN | ||||||||
AuthorizedOfficialFirstName: | CHARLOTTE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3177061600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 060034971 | IN | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
ID | Type | State | Issuer | Description | 200464700B | 05 | IN |   | MEDICAID |