Basic Information
| Provider Information | |||||||||
| NPI: | 1538119219 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOSEPHSON WALLACK MUNSHOWER NEUROLOGY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JWM NEUROLOGY PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6983 HILLSDALE CT | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178498350 | ||||||||
| FaxNumber: | 3175766311 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 N RITTER AVE | ||||||||
| Address2: | STE 220 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462193046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177155600 | ||||||||
| FaxNumber: | 3177155618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 04/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | JACQUAY | ||||||||
| AuthorizedOfficialFirstName: | HERSCHAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3173082828 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JOSEPHSON WALLACK MUNSHOWER NEUROLOGY PC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 100218760A | 05 | IN | MEDICAID | CJ9849 | 01 | MEDICARE RR | OTHER |