Basic Information
| Provider Information | |||||||||
| NPI: | 1902894074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HABIMANA | ||||||||
| FirstName: | THOMAS | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11460 N MERIDIAN ST | ||||||||
| Address2: | STE. 110 | ||||||||
| City: | CARMEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460324408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175672180 | ||||||||
| FaxNumber: | 3176149655 | ||||||||
| Practice Location | |||||||||
| Address1: | 3630 GUION RD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462221616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179208439 | ||||||||
| FaxNumber: | 3176149655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1097396 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 28122164A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 74005273 | 05 | KY | MEDICAID | 000000283641 | 01 | KY | ANTHEM BLUE SHIELD | OTHER | 200428210 | 05 | IN | MEDICAID | 430080249 | 01 | RAILROAD MEDICARE | OTHER | 2773493000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 50012416 | 01 | KY | PASSPORT | OTHER |