Healthcare Provider Details

I. General information

NPI: 1326099755
Provider Name (Legal Business Name): AZARIAS SHAMUS LONBERGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W 10TH ST MEDICINE 111
INDIANAPOLIS IN
46202-2803
US

IV. Provider business mailing address

5901 PENWAY ST
INDIANAPOLIS IN
46224-1236
US

V. Phone/Fax

Practice location:
  • Phone: 317-554-0181
  • Fax: 317-554-0105
Mailing address:
  • Phone: 317-328-5230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01059165A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: