Provider Demographics
NPI:1083796221
Name:SOUTHERN INDIANA SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHERN INDIANA SURGERY CENTER, LLC
Other - Org Name:SOUTHERN INDIANA SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-333-8969
Mailing Address - Street 1:2800 REX GROSSMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5145
Mailing Address - Country:US
Mailing Address - Phone:812-333-8969
Mailing Address - Fax:812-335-2309
Practice Address - Street 1:2800 REX GROSSMAN BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5145
Practice Address - Country:US
Practice Address - Phone:812-333-8969
Practice Address - Fax:812-335-2309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06-006102-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100274500AMedicaid
INZB0360Medicare UPIN