Provider Demographics
NPI:1336209303
Name:SYCAMORE ANESTHESIA SERVICES, LLC
Entity Type:Organization
Organization Name:SYCAMORE ANESTHESIA SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:PENDERGAST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-231-4608
Mailing Address - Street 1:PO BOX 3036
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3036
Mailing Address - Country:US
Mailing Address - Phone:812-231-4608
Mailing Address - Fax:812-231-4675
Practice Address - Street 1:1421 N 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1005
Practice Address - Country:US
Practice Address - Phone:812-231-4608
Practice Address - Fax:812-231-4675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200331190Medicaid
INCJ6341Medicare PIN
IN226030Medicare PIN