Basic Information
| Provider Information | |||||||||
| NPI: | 1851372346 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | TROY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178651479 | ||||||||
| Practice Location | |||||||||
| Address1: | 5454 HOHMAN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199322300 | ||||||||
| FaxNumber: | 2198522502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 11738 | MT | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | DR.0056684 | CO | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 01076416A | IN | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 201347360 | 05 | IN | MEDICAID |