Basic Information
| Provider Information | |||||||||
| NPI: | 1336209303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SYCAMORE ANESTHESIA SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3036 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462063036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122314608 | ||||||||
| FaxNumber: | 8122314675 | ||||||||
| Practice Location | |||||||||
| Address1: | 1421 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478071005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122314608 | ||||||||
| FaxNumber: | 8122314675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 01/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | PENDERGAST | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8122314608 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200331190 | 05 | IN | MEDICAID |