Basic Information
Provider Information | |||||||||
NPI: | 1487741641 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JOSEPHSON WALLACK MUNSHOWER NEUROLOGY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JWM NEUROLOGY PC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6983 HILLSDALE CT | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462502054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178498350 | ||||||||
FaxNumber: | 3175766311 | ||||||||
Practice Location | |||||||||
Address1: | 1 MEMORIAL SQ | ||||||||
Address2: | STE 355 | ||||||||
City: | GREENFIELD | ||||||||
State: | IN | ||||||||
PostalCode: | 461402835 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3174620657 | ||||||||
FaxNumber: | 3173551108 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/09/2006 | ||||||||
LastUpdateDate: | 09/12/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JACQUAY | ||||||||
AuthorizedOfficialFirstName: | HERSCHAL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3178498350 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | JOSEPHSON WALLACK MUNSHOWER NEUROLOGY PC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X |   | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | CJ9849 | 01 |   | MEDICARE RR | OTHER | 100218760E | 05 | IN |   | MEDICAID |