Basic Information
| Provider Information | |||||||||
| NPI: | 1942409982 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEGERREIS | ||||||||
| FirstName: | SAMUEL | ||||||||
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| Credential: | PT/ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 PENNSYLVANIA PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462802301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178171200 | ||||||||
| FaxNumber: | 3172081551 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 PENNSYLVANIA PKWY | ||||||||
| Address2: | STE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462802301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178171200 | ||||||||
| FaxNumber: | 3172081551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2007 | ||||||||
| LastUpdateDate: | 02/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05001348A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 201003100 | 05 | IN | MEDICAID |