Basic Information
| Provider Information | |||||||||
| NPI: | 1639430101 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOSEPHSON WALLACK MUNSHOWER NEUROLOGY PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JWM NEUROLOGY PC ELWOOD OFFICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6983 HILLSDALE CT | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173082828 | ||||||||
| FaxNumber: | 3175766311 | ||||||||
| Practice Location | |||||||||
| Address1: | 1331 S A ST | ||||||||
| Address2: | |||||||||
| City: | ELWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460361942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654558822 | ||||||||
| FaxNumber: | 7658653935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2012 | ||||||||
| LastUpdateDate: | 09/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | JACQUAY | ||||||||
| AuthorizedOfficialFirstName: | HERSCHAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3173082828 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JOSEPHSON WALLACK MUNSHOWER NEUROLOGY PC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 100218760 | 05 | IN | MEDICAID |