Healthcare Provider Details

I. General information

NPI: 1104197326
Provider Name (Legal Business Name): JULIAN UNGAR-SARGON MD PHD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2012
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 S MCKINLEY AVE
RENSSELAER IN
47978
US

IV. Provider business mailing address

123 S MCKINLEY AVE
RENSSELAER IN
47978-2949
US

V. Phone/Fax

Practice location:
  • Phone: 219-866-7222
  • Fax: 219-866-7001
Mailing address:
  • Phone: 219-866-7222
  • Fax: 219-866-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number01040129A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number01040129A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number01040129A
License Number StateIN

VIII. Authorized Official

Name: JULIAN Y UNGAR-SARGON
Title or Position: OWNER / MD
Credential: MD, PHD
Phone: 219-866-7222