=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295105641
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHERIDAN EMERGENCY PHYSICIAN SERVICES OF INDIANA, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2015
-----------------------------------------------------
Last Update Date | 08/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4011 S MONROE MEDICAL PARK BLVD
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47403-8000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-825-0802
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 453668
-----------------------------------------------------
City | SUNRISE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33345-3668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GILBERT DROZDOW
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 954-838-2371
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------