Provider Demographics
NPI:1457332413
Name:SOUTHEASTERN INDIANA GASTROENTEROLOGY
Entity Type:Organization
Organization Name:SOUTHEASTERN INDIANA GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATIENT ACCOUNT REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:BILLING OFFICE
Authorized Official - Phone:812-372-8680
Mailing Address - Street 1:2630 22ND ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-3702
Mailing Address - Country:US
Mailing Address - Phone:812-372-8680
Mailing Address - Fax:812-372-9265
Practice Address - Street 1:2630 22ND ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-3702
Practice Address - Country:US
Practice Address - Phone:812-372-8680
Practice Address - Fax:812-372-9265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2020-08-22
Deactivation Date:2006-03-07
Deactivation Code:
Reactivation Date:2006-12-20
Provider Licenses
StateLicense IDTaxonomies
IN01033813A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN050176POtherSIHO PROVIDER NUMBER
IN000000317541OtherICHIA PROVIDER NUMBER
IN000000317541OtherANTHEM
IN050176POtherSIHO PROVIDER NUMBER