Provider Demographics
NPI:1588673560
Name:GLHS ANESTHESIA GROUP
Entity Type:Organization
Organization Name:GLHS ANESTHESIA GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PHALEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-554-4548
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1701 S CREASY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4972
Practice Address - Country:US
Practice Address - Phone:765-502-4917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300029746Medicaid
IN200520240AMedicaid
IN200520240BMedicaid
IN300029249Medicaid