Provider Demographics
NPI:1003996166
Name:PEDIATRIC ASSOCIATES OF SOUTHERN INDIANA
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF SOUTHERN INDIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-945-2229
Mailing Address - Street 1:1425 STATE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-4909
Mailing Address - Country:US
Mailing Address - Phone:812-945-2229
Mailing Address - Fax:812-949-2229
Practice Address - Street 1:1425 STATE ST STE 100
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4909
Practice Address - Country:US
Practice Address - Phone:812-945-2229
Practice Address - Fax:812-949-2229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100382640Medicaid
IN=========OtherTAX ID#