Basic Information
| Provider Information | |||||||||
| NPI: | 1598746133 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HANCOCK ANESTHESIA GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 68952 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462680952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178718261 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461401270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178718261 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 04/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | STOTT | ||||||||
| AuthorizedOfficialFirstName: | BLAIR | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3178718261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 200254340 | 05 | IN | MEDICAID | 200254340A | 05 | IN | MEDICAID |