Provider Demographics
NPI:1780689984
Name:STANISH, PAUL J (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:J
Last Name:STANISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1400 S LAKE PARK AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-6791
Mailing Address - Country:US
Mailing Address - Phone:219-947-6122
Mailing Address - Fax:219-947-6045
Practice Address - Street 1:1400 S LAKE PARK AVE
Practice Address - Street 2:STE 200
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6791
Practice Address - Country:US
Practice Address - Phone:219-947-6122
Practice Address - Fax:219-947-6045
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01042582208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000092005OtherANTHEM PROVIDER NUMBER
IN90001166OtherBC/BS OF ILLINOIS PROV #
IN020037867OtherRR MCR PROVIDER #
IN100473240BMedicaid
IN100473240BMedicaid
IN020037867OtherRR MCR PROVIDER #