Provider Demographics
NPI:1720023799
Name:WABASH VALLEY ANESTHESIA
Entity Type:Organization
Organization Name:WABASH VALLEY ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCGREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:317-218-3136
Mailing Address - Street 1:PO BOX 1701
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46061-1701
Mailing Address - Country:US
Mailing Address - Phone:317-218-3136
Mailing Address - Fax:317-669-0439
Practice Address - Street 1:15788 HAZEL DELL RD
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-6911
Practice Address - Country:US
Practice Address - Phone:317-218-3136
Practice Address - Fax:317-669-0439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200242920Medicaid
IN146000Medicare PIN