Provider Demographics
NPI:1154857548
Name:OBSIDIAN SURGICAL LLC
Entity Type:Organization
Organization Name:OBSIDIAN SURGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-399-4567
Mailing Address - Street 1:1805 BEAUFAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-7202
Mailing Address - Country:US
Mailing Address - Phone:317-399-4567
Mailing Address - Fax:
Practice Address - Street 1:10090 E US HIGHWAY 36
Practice Address - Street 2:SUITE D
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8175
Practice Address - Country:US
Practice Address - Phone:317-399-4567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068593A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01068593AOtherMEDICAL LICENSE