Provider Demographics
NPI:1528070224
Name:MIDWEST COLON & RECTAL SURGERY INC
Entity type:Organization
Organization Name:MIDWEST COLON & RECTAL SURGERY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-844-5273
Mailing Address - Street 1:13421 OLD MERIDIAN ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1427
Mailing Address - Country:US
Mailing Address - Phone:317-844-5273
Mailing Address - Fax:317-844-5709
Practice Address - Street 1:13421 OLD MERIDIAN ST
Practice Address - Street 2:SUITE 210
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1427
Practice Address - Country:US
Practice Address - Phone:317-844-5273
Practice Address - Fax:317-844-5709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200107880AMedicaid
IN200107880AMedicaid