Provider Demographics
NPI:1780864926
Name:SHADELAND ANESTHESIA
Entity Type:Organization
Organization Name:SHADELAND ANESTHESIA
Other - Org Name:CENTER FOR PAIN MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OF CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISGERBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-706-3415
Mailing Address - Street 1:8805 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2760
Mailing Address - Country:US
Mailing Address - Phone:317-706-3415
Mailing Address - Fax:317-706-3419
Practice Address - Street 1:8805 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2760
Practice Address - Country:US
Practice Address - Phone:317-706-3415
Practice Address - Fax:317-706-3419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN154505Medicare PIN