Healthcare Provider Details

I. General information

NPI: 1245497890
Provider Name (Legal Business Name): ROSS RICHARD HAYNES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8111 S EMERSON AVE
INDIANAPOLIS IN
46237-8601
US

IV. Provider business mailing address

PO BOX 6069 DEPT 107
INDIANAPOLIS IN
46206-6069
US

V. Phone/Fax

Practice location:
  • Phone: 317-870-6736
  • Fax: 317-870-0499
Mailing address:
  • Phone: 317-870-6736
  • Fax: 317-870-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number11013790A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: