Provider Demographics
NPI:1154589554
Name:CARDIOTHORACIC SURGEONS OF INDIANA LLC
Entity type:Organization
Organization Name:CARDIOTHORACIC SURGEONS OF INDIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALASTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-621-8050
Mailing Address - Street 1:8075 N SHADELAND AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2693
Mailing Address - Country:US
Mailing Address - Phone:317-621-8640
Mailing Address - Fax:317-621-8644
Practice Address - Street 1:8075 N SHADELAND AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2693
Practice Address - Country:US
Practice Address - Phone:317-621-8640
Practice Address - Fax:317-621-8644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200910050Medicaid
IN000000569471OtherANTHEM
IN9615187OtherAETNA
IN9615187OtherAETNA