Basic Information
| Provider Information | |||||||||
| NPI: | 1316966229 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY SURGEONS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | STE 130 PROVIDER ENROLLMENT | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179624942 | ||||||||
| FaxNumber: | 3179624343 | ||||||||
| Practice Location | |||||||||
| Address1: | 545 BARNHILL DR | ||||||||
| Address2: | EH 517 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172743086 | ||||||||
| FaxNumber: | 3172781886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 12/16/2013 | ||||||||
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| AuthorizedOfficialLastName: | MCLARREN | ||||||||
| AuthorizedOfficialFirstName: | VANCE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR FINANCES | ||||||||
| AuthorizedOfficialTelephone: | 3172743086 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 2086S0102X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200086410 | 05 | IN | MEDICAID |