Basic Information
| Provider Information | |||||||||
| NPI: | 1629258470 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANDERSON GENERAL SURGERY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 N GRANVILLE AVE | ||||||||
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| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473032110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652840493 | ||||||||
| FaxNumber: | 7652842434 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 MEDICAL ARTS BLVD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | ANDERSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460113458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652984250 | ||||||||
| FaxNumber: | 7652984960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
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| AuthorizedOfficialLastName: | SIADATI | ||||||||
| AuthorizedOfficialFirstName: | MOHAMMAD | ||||||||
| AuthorizedOfficialMiddleName: | REZA | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7652784227 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 01048160A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.