=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528014362
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOSHEN ANESTHESIOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 HIGH PARK AVE
-----------------------------------------------------
City | GOSHEN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46526-4810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-273-6546
-----------------------------------------------------
Fax | 574-273-5295
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P O BOX 661172
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46266-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-273-6546
-----------------------------------------------------
Fax | 574-273-5295
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. POOPALASINGHAM POOVENDRAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 574-273-6546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------