Basic Information
| Provider Information | |||||||||
| NPI: | 1568417442 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANDY | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 NORTH BALDWIN AVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469522542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 830 N THEATRE DRIVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469521700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656624142 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 09/06/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | 01059985A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | 01059985A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200509010 | 05 | IN | MEDICAID | 000000519329 | 01 | IN | ANTHEM | OTHER | P00414325 | 01 | IN | MEDICARE RAILROAD | OTHER |