Healthcare Provider Details

I. General information

NPI: 1225296734
Provider Name (Legal Business Name): INDIANA UNIVERSITY SCHOOL OF MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 12/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 BARNHILL DR EMERSON HALL 203
INDIANAPOLIS IN
46202-5112
US

IV. Provider business mailing address

6015 MAPLE FORGE CIR
INDIANAPOLIS IN
46254-1266
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number11012602A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number11012062A
License Number StateIN

VIII. Authorized Official

Name: DR. ALYSSA DANIELLE FAJARDO
Title or Position: SURGERY RESIDENT
Credential: MD
Phone: 317-312-0265