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Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
MD

Contact information

Practice address
1600 ALBANY ST, BEECH GROVE, IN 46107-1541
(317) 567-2179
(317) 567-2191
Mailing address
PO BOX 6069, DEPT 107, INDIANAPOLIS, IN 46206-6069
(317) 567-2180
(317) 567-2191

Taxonomy

Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
01040059
IN

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
100196700
IN
Enumeration date
07/14/2006
Last updated
10/30/2008
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