Provider Demographics
NPI:1639164999
Name:CREEKSIDE OBGYN PC
Entity Type:Organization
Organization Name:CREEKSIDE OBGYN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-483-7361
Mailing Address - Street 1:2505 N LEBANON ST
Mailing Address - Street 2:STE 208
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-8612
Mailing Address - Country:US
Mailing Address - Phone:765-485-8444
Mailing Address - Fax:765-483-7365
Practice Address - Street 1:2505 N LEBANON ST
Practice Address - Street 2:STE 208
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-8612
Practice Address - Country:US
Practice Address - Phone:765-485-8444
Practice Address - Fax:765-483-7365
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WITHAM MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-13
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50004241A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200293550Medicaid
161990Medicare ID - Type Unspecified