Provider Demographics
NPI:1407883960
Name:ANTALIS, SARAH (MD)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:ANTALIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:SARAH
Other - Middle Name:
Other - Last Name:FRUIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:253 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:W LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1501
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01069600A207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001016017OtherANTHEM PIN - URGENT CARE UNDER TIN 35-2030653
IN201028020Medicaid
HI588907-11Medicaid
IN000000719631OtherANTHEM PROVIDER NUMBER
HI00A0261717OtherHMSA BILLING NUMBER
IN000000719631OtherANTHEM PROVIDER NUMBER
HII63287Medicare UPIN
HI588907-11Medicaid
INM400052359Medicare PIN