Healthcare Provider Details

I. General information

NPI: 1750302709
Provider Name (Legal Business Name): MADISON ANESTHESIA GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 JACKSON ST
ANDERSON IN
46016-4337
US

IV. Provider business mailing address

PO BOX 112
MUNCIE IN
47308-0112
US

V. Phone/Fax

Practice location:
  • Phone: 765-649-2511
  • Fax:
Mailing address:
  • Phone: 765-284-0493
  • Fax: 765-284-2434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KASHIF ABDUL-RAHMAN
Title or Position: MD
Credential: MD
Phone: 765-284-0493