MEDICARE: DR. STANLEY E. OSMUNSON ED.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	20040222A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000184223	OTHER	IN	ANTHEM BLUE CROSS BLUE SH

General Provider Information

NPI Number	:	1659443240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STANLEY E. OSMUNSON ED.D.

Provider Business Mailing Address
First Line	:	3850 SHORE DR STE 303
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-4693
Country	:	US
Telephone Number	:	317-328-1200
Fax Number	:	317-328-1200

Provider Business Practice Location Address
First Line	:	3850 SHORE DR STE 303
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-4693
Country	:	US
Telephone Number	:	317-328-1200
Fax Number	:	317-328-1200

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	07/08/2007

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