Provider Demographics
NPI:1558442715
Name:KANIS, JESSICA M (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:M
Last Name:KANIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:FANGMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 RILEY DRIVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-3936
Practice Address - Fax:317-948-5844
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.094922208000000X
IN01072885A208000000X, 2083C0008X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2083C0008XAllopathic & Osteopathic PhysiciansPreventive MedicineClinical Informatics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201057370Medicaid
IN000000835642OtherANTHEM PIN
IN000000835642OtherANTHEM PIN