Provider Demographics
NPI:1023292646
Name:DR. JON J. STANICH P.C.
Entity type:Organization
Organization Name:DR. JON J. STANICH P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:STANICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-823-7000
Mailing Address - Street 1:PO BOX 36365
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-0365
Mailing Address - Country:US
Mailing Address - Phone:317-823-7000
Mailing Address - Fax:317-823-7002
Practice Address - Street 1:10830 PENDLETON PIKE
Practice Address - Street 2:SUITE E
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-3300
Practice Address - Country:US
Practice Address - Phone:317-823-7000
Practice Address - Fax:317-823-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001077111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100119420Medicaid
IN274850Medicare PIN