Basic Information
| Provider Information | |||||||||
| NPI: | 1780864926 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHADELAND ANESTHESIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTER FOR PAIN MANAGEMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8805 N MERIDIAN ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462602760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177063415 | ||||||||
| FaxNumber: | 3177063419 | ||||||||
| Practice Location | |||||||||
| Address1: | 8805 N MERIDIAN ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462602760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177063415 | ||||||||
| FaxNumber: | 3177063419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2007 | ||||||||
| LastUpdateDate: | 11/05/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEISGERBER | ||||||||
| AuthorizedOfficialFirstName: | ANGIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER OF CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 3177063415 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0401X | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
No ID Information.