=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134162274
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAN FISHER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2400 SOUTH ST
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47904-3027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-449-3090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2213 STATE ROAD 225 E
-----------------------------------------------------
City | BATTLE GROUND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47920-9438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-427-5077
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 01026232
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------