Provider Demographics
NPI:1093099012
Name:ELIZABETH S. MATEOS-TIONGCO
Entity Type:Organization
Organization Name:ELIZABETH S. MATEOS-TIONGCO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:SANCHEZ
Authorized Official - Last Name:MATEOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-659-2030
Mailing Address - Street 1:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:IN
Mailing Address - Zip Code:47443-0236
Mailing Address - Country:US
Mailing Address - Phone:812-659-2030
Mailing Address - Fax:812-659-7601
Practice Address - Street 1:195 E BROAD ST
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:IN
Practice Address - Zip Code:47443-9502
Practice Address - Country:US
Practice Address - Phone:812-659-2030
Practice Address - Fax:812-659-7601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033055A207V00000X
IN01033055B207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100124750AMedicaid
IN160025634OtherRAILROAD MED
IN1790783637OtherCOMMERICAL
IN000000084916OtherBCBS
C24808Medicare UPIN
IN100124750AMedicaid