Healthcare Provider Details

I. General information

NPI: 1154537850
Provider Name (Legal Business Name): CARDIOTHORACIC SURGEONS PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 BARNHILL DR # EH215
INDIANAPOLIS IN
46202-5112
US

IV. Provider business mailing address

PO BOX 636762
CINCINNATI OH
45263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 317-948-0944
  • Fax:
Mailing address:
  • Phone: 317-948-7048
  • Fax: 317-274-2940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: TERESA KRUSE
Title or Position: BUSINESS LINE ADMINISTRATOR
Credential:
Phone: 317-948-0944