Healthcare Provider Details

I. General information

NPI: 1649292806
Provider Name (Legal Business Name): ASSOCIATES IN SURGERY OF MUNCIE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 W ROYALE DR
MUNCIE IN
47304-2243
US

IV. Provider business mailing address

1812 WEST ROYALE DR
MUNCIE IN
47304
US

V. Phone/Fax

Practice location:
  • Phone: 765-284-7703
  • Fax: 765-284-6838
Mailing address:
  • Phone: 765-284-7703
  • Fax: 765-284-6838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number50001085A
License Number StateIN

VIII. Authorized Official

Name: MRS. THELMA YOST
Title or Position: PRACTICE MANAGER
Credential:
Phone: 765-284-7703