Basic Information
| Provider Information | |||||||||
| NPI: | 1639253792 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HOSPITALS OF IN, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEDICAL PSYCHOLOGISTS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19751 | ||||||||
| Address2: | LOWER LEVEL PT ACCTS | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462190751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173555837 | ||||||||
| FaxNumber: | 3173552205 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 N RITTER AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462193027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173555837 | ||||||||
| FaxNumber: | 3173552205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 05/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | FISCHER | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3173554887 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HOSPITALS OF IN, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | C.P.A. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 248681-000 | 01 | IN | MAGELLAN | OTHER | CA6165 | 01 | IN | RAILROAD MEDICARE | OTHER | 100415610A | 05 | IN | MEDICAID |