Basic Information
| Provider Information | |||||||||
| NPI: | 1417966276 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GATHINGS | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11432 FAIRPORT CIR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462369017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178236918 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1373 E STATE ROAD 62 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472507328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128010800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 05/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 47634 | WI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 20089950 | 05 | IN | MEDICAID | 412840143 | 01 | IN | MEDICARE | OTHER | 7100775580 | 05 | KY | MEDICAID |