Healthcare Provider Details

I. General information

NPI: 1144314097
Provider Name (Legal Business Name): MANDELBAUM SURGICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 E STOP 11 RD SUITE 450
INDIANAPOLIS IN
46237-6340
US

IV. Provider business mailing address

5255 E STOP 11 RD SUITE 450
INDIANAPOLIS IN
46237-6340
US

V. Phone/Fax

Practice location:
  • Phone: 317-856-4800
  • Fax: 317-865-4806
Mailing address:
  • Phone: 317-856-4800
  • Fax: 317-865-4806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DENA L PETTY
Title or Position: MANAGER
Credential:
Phone: 317-865-4800