Provider Demographics
NPI:1871668582
Name:INDIANA EPILEPSY AND CHILD NEUROLOGY, INC.
Entity Type:Organization
Organization Name:INDIANA EPILEPSY AND CHILD NEUROLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:STAUFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-426-9996
Mailing Address - Street 1:4310 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-7222
Mailing Address - Country:US
Mailing Address - Phone:260-426-9996
Mailing Address - Fax:260-426-9996
Practice Address - Street 1:4310 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-7222
Practice Address - Country:US
Practice Address - Phone:260-426-9996
Practice Address - Fax:260-426-9996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200680Medicare PIN