Provider Demographics
NPI:1063887115
Name:ANDERSON, EILISH MARY (ATC)
Entity type:Individual
Prefix:
First Name:EILISH
Middle Name:MARY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PENNSYLVANIA PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46280-1393
Mailing Address - Country:US
Mailing Address - Phone:317-817-1200
Mailing Address - Fax:
Practice Address - Street 1:201 PENNSYLVANIA PKWY STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280-1393
Practice Address - Country:US
Practice Address - Phone:317-817-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36003061A2255A2300X
IL096.0039932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer