Provider Demographics
NPI:1225129570
Name:PLASTIC SURGERY ASSOCIATES OF SOUTHERN INDIANA PC
Entity Type:Organization
Organization Name:PLASTIC SURGERY ASSOCIATES OF SOUTHERN INDIANA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CHAIR OF GOVERNING BODY
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:812-336-6060
Mailing Address - Street 1:PO BOX 1148
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1148
Mailing Address - Country:US
Mailing Address - Phone:812-336-6060
Mailing Address - Fax:812-333-7760
Practice Address - Street 1:1455 W 2ND STREET
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403
Practice Address - Country:US
Practice Address - Phone:812-336-6060
Practice Address - Fax:812-333-7760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50003776A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
547930Medicare ID - Type Unspecified