Provider Demographics
NPI:1093901480
Name:SOUTHERN MEDICAL CORPORATION PC
Entity Type:Organization
Organization Name:SOUTHERN MEDICAL CORPORATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERYLE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:SOUTHERN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-923-1274
Mailing Address - Street 1:6433 E WASHINGTON ST
Mailing Address - Street 2:SUITE 125
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-6677
Mailing Address - Country:US
Mailing Address - Phone:317-923-1274
Mailing Address - Fax:317-924-4436
Practice Address - Street 1:6433 E WASHINGTON ST
Practice Address - Street 2:SUITE 125
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-6677
Practice Address - Country:US
Practice Address - Phone:317-923-1274
Practice Address - Fax:317-924-4436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033547A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100237790AMedicaid
IN000000086109OtherANTHEM
IN110014372OtherRAILROAD MEDICARE
IN000000086109OtherANTHEM
IN=========OtherTRICARE
IN100237790AMedicaid