Provider Demographics
NPI:1114006137
Name:SONDGERATH, SCOTT M (CRNA)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:M
Last Name:SONDGERATH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5487 N 1000 E
Mailing Address - Street 2:
Mailing Address - City:OTTERBEIN
Mailing Address - State:IN
Mailing Address - Zip Code:47970-8080
Mailing Address - Country:US
Mailing Address - Phone:765-583-2765
Mailing Address - Fax:
Practice Address - Street 1:5487 N 1000 E
Practice Address - Street 2:
Practice Address - City:OTTERBEIN
Practice Address - State:IN
Practice Address - Zip Code:47970-8080
Practice Address - Country:US
Practice Address - Phone:765-583-2765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28115782367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001075174OtherANTHEM PROVIDER NUMBER
IN815500193Medicare PIN
IN000001075174OtherANTHEM PROVIDER NUMBER