Healthcare Provider Details

I. General information

NPI: 1114941259
Provider Name (Legal Business Name): ADAM R WALTHALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8111 S EMERSON AVE
INDIANAPOLIS IN
46237-8601
US

IV. Provider business mailing address

450 E 96TH ST STE 200
INDIANAPOLIS IN
46240-3797
US

V. Phone/Fax

Practice location:
  • Phone: 317-566-1000
  • Fax:
Mailing address:
  • Phone: 317-566-1000
  • Fax: 317-566-1700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01057200
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: