Basic Information
| Provider Information | |||||||||
| NPI: | 1750302709 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MADISON ANESTHESIA GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 112 | ||||||||
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| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473080112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652840493 | ||||||||
| FaxNumber: | 7652842434 | ||||||||
| Practice Location | |||||||||
| Address1: | 2015 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460164337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656492511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 08/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | ABDUL-RAHMAN | ||||||||
| AuthorizedOfficialFirstName: | KASHIF | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 7652840493 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100170520 | 05 | IN | MEDICAID | 100092460 | 05 | IN | MEDICAID | 100375750 | 05 | IN | MEDICAID | 100173130 | 05 | IN | MEDICAID |