Provider Demographics
NPI:1689761843
Name:JOSEPHSON WALLACK MUNSHOWER NEUROLOGY PC
Entity type:Organization
Organization Name:JOSEPHSON WALLACK MUNSHOWER NEUROLOGY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/CIO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-308-2800
Mailing Address - Street 1:6983 HILLSDALE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2054
Mailing Address - Country:US
Mailing Address - Phone:317-849-8350
Mailing Address - Fax:317-576-6311
Practice Address - Street 1:8402 HARCOURT RD STE 615
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2055
Practice Address - Country:US
Practice Address - Phone:317-806-6991
Practice Address - Fax:317-806-6990
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOSEPHSON WALLACK MUNSHOWER NEUROLOGY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-09
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100218760CMedicaid
CJ9849OtherMEDICARE RR
CJ9849OtherMEDICARE RR