=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043460041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIANA PERFUSION SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2008
-----------------------------------------------------
Last Update Date | 09/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1315 N ARLINGTON AVE #220
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46219-3278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-353-2548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1315 N ARLINGTON AVE #220
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46219-3278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-353-2548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. JEAN P. MERCHO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 317-697-3141
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------