Provider Demographics
NPI:1518965169
Name:FOGELSON, BERNARD (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:
Last Name:FOGELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8180 CLEARVISTA PARKWAY
Mailing Address - Street 2:SUITE 230
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-4649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3611 S REED RD
Practice Address - Street 2:SUITE 103
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3828
Practice Address - Country:US
Practice Address - Phone:765-864-5786
Practice Address - Fax:765-864-5787
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058072A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200450400Medicaid
IN247230AMedicare PIN