Provider Demographics
NPI:1518085661
Name:INTERNAL MEDICINE OF SOUTH EAST INDIANA
Entity Type:Organization
Organization Name:INTERNAL MEDICINE OF SOUTH EAST INDIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-933-1858
Mailing Address - Street 1:1088 STATE ROAD 229
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47006-6810
Mailing Address - Country:US
Mailing Address - Phone:812-933-1858
Mailing Address - Fax:812-933-1968
Practice Address - Street 1:1088 STATE ROAD 229
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:IN
Practice Address - Zip Code:47006-6810
Practice Address - Country:US
Practice Address - Phone:812-933-1858
Practice Address - Fax:812-933-1968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052054A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1518085661Medicaid
IN200245400BMedicaid
IN200245400BMedicaid
IND88682Medicare UPIN