Provider Demographics
NPI:1003000399
Name:RECONSTRUCTIVE HAND TO SHOULDER OF INDIANA, LLC
Entity Type:Organization
Organization Name:RECONSTRUCTIVE HAND TO SHOULDER OF INDIANA, LLC
Other - Org Name:RECONSTRUCTIVE HAND SURGEONS OF INDIANA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:PANNUNZIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-249-2616
Mailing Address - Street 1:13431 OLD MERIDIAN STREET
Mailing Address - Street 2:SUITE 225
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032
Mailing Address - Country:US
Mailing Address - Phone:317-249-2616
Mailing Address - Fax:317-249-2618
Practice Address - Street 1:13431 OLD MERIDIAN STREET
Practice Address - Street 2:SUITE 225
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032
Practice Address - Country:US
Practice Address - Phone:317-249-2616
Practice Address - Fax:317-249-2618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01063681AOtherMEDICAL LICENSE
IN252680Medicare UPIN
IN01063681AOtherMEDICAL LICENSE
IND94498Medicare UPIN
IN90579Medicare UPIN
IN6019520001Medicare NSC
INH21285Medicare UPIN