Provider Demographics
NPI:1124372131
Name:SCOTTSBURG FAMILY HEALTHCARE INC
Entity Type:Organization
Organization Name:SCOTTSBURG FAMILY HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:AVERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-752-1151
Mailing Address - Street 1:PO BOX 290
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-0290
Mailing Address - Country:US
Mailing Address - Phone:812-752-1151
Mailing Address - Fax:812-752-1152
Practice Address - Street 1:1465 N. GARDNER ST.
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-7751
Practice Address - Country:US
Practice Address - Phone:812-752-1151
Practice Address - Fax:812-752-1152
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SCOTTSBURG FAMILY HEALTHCARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-30
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045558A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200179420BMedicaid
G10565Medicare UPIN