Healthcare Provider Details

I. General information

NPI: 1114006137
Provider Name (Legal Business Name): SCOTT M SONDGERATH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5487 N 1000 E
OTTERBEIN IN
47970-8080
US

IV. Provider business mailing address

5487 N 1000 E
OTTERBEIN IN
47970-8080
US

V. Phone/Fax

Practice location:
  • Phone: 765-583-2765
  • Fax:
Mailing address:
  • Phone: 765-583-2765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28115782
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: