Provider Demographics
NPI:1386668812
Name:SIGMA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:SIGMA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-775-2828
Mailing Address - Street 1:1415 SALEM ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2099
Mailing Address - Country:US
Mailing Address - Phone:765-449-2410
Mailing Address - Fax:765-742-8607
Practice Address - Street 1:1701 S CREASY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4972
Practice Address - Country:US
Practice Address - Phone:765-775-2828
Practice Address - Fax:765-775-2833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200495560Medicaid