Basic Information
| Provider Information | |||||||||
| NPI: | 1538195169 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR SPECIAL SURGERY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8805 N MERIDIAN ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462602332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177067246 | ||||||||
| FaxNumber: | 3177063419 | ||||||||
| Practice Location | |||||||||
| Address1: | 8805 N MERIDIAN ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462602332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177067246 | ||||||||
| FaxNumber: | 3177063419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 01/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | MANDABACH | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3177067246 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 060030321 | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 200365010A | 05 | IN | MEDICAID |