Provider Demographics
NPI:1003074972
Name:INDIANA UNIVERSITY HEALTH SOUTHERN INDIANA PHYSICIANS LLC
Entity Type:Organization
Organization Name:INDIANA UNIVERSITY HEALTH SOUTHERN INDIANA PHYSICIANS LLC
Other - Org Name:GOSPORT FAMILY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATION, IU HEALTH SIP
Authorized Official - Prefix:MR
Authorized Official - First Name:MARLON
Authorized Official - Middle Name:B
Authorized Official - Last Name:FISHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-353-5866
Mailing Address - Street 1:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1329
Mailing Address - Country:US
Mailing Address - Phone:812-879-4222
Mailing Address - Fax:812-879-4834
Practice Address - Street 1:7 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GOSPORT
Practice Address - State:IN
Practice Address - Zip Code:47433-7034
Practice Address - Country:US
Practice Address - Phone:812-879-4222
Practice Address - Fax:812-879-4834
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDIANA UNIVERSITY HEALTH BLOOMINGTON INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-28
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200874400AMedicaid
INCI4187OtherRAILROAD MEDICARE
IN610590Medicare PIN
IN153884Medicare Oscar/Certification