Healthcare Provider Details

I. General information

NPI: 1093757478
Provider Name (Legal Business Name): EMGI CLARIAN WEST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 02/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 RONALD REAGAN PKWY
AVON IN
46123-7085
US

IV. Provider business mailing address

2449 RELIABLE PARKWAY
CHICAGO IL
60686-0001
US

V. Phone/Fax

Practice location:
  • Phone: 317-802-3146
  • Fax:
Mailing address:
  • Phone: 317-802-3146
  • Fax: 317-870-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES SHUFFLEBARGER
Title or Position: PRESIDENT
Credential: MD
Phone: 317-802-3146