=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609889526
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIANA GENERAL SURGERY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2006
-----------------------------------------------------
Last Update Date | 12/11/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3520 GUION RD SUITE 301
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46222-1692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-924-4009
-----------------------------------------------------
Fax | 317-926-8410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3520 GUION RD SUITE 301
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46222-1692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-924-4009
-----------------------------------------------------
Fax | 317-926-8410
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MRS. WENDY L BUCKLER
-----------------------------------------------------
Credential | CMM
-----------------------------------------------------
Telephone | 317-924-4009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------