Provider Demographics
NPI:1275872673
Name:JOSEPHSON WALLACK MUNSHOWER NEUROLOGY PC
Entity Type:Organization
Organization Name:JOSEPHSON WALLACK MUNSHOWER NEUROLOGY PC
Other - Org Name:CENTRAL INDIANA NEUROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/CIO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:EARWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-849-8350
Mailing Address - Street 1:6983 HILLSDALE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2054
Mailing Address - Country:US
Mailing Address - Phone:317-308-2828
Mailing Address - Fax:317-576-6311
Practice Address - Street 1:1210 MEDICAL ARTS BLVD STE 114
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3442
Practice Address - Country:US
Practice Address - Phone:765-298-4545
Practice Address - Fax:765-298-4945
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOSEPHSON WALLACK MUNSHOWER NEUROLOGY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100218760PMedicaid
INCJ9849OtherMEDICARE RR