Provider Demographics
NPI:1811043854
Name:SOUTHERN INDIANA PEDIATRICS P.S.C.
Entity Type:Organization
Organization Name:SOUTHERN INDIANA PEDIATRICS P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GULLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-282-1367
Mailing Address - Street 1:1701 SPRING ST
Mailing Address - Street 2:SUITE A.
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-2930
Mailing Address - Country:US
Mailing Address - Phone:812-282-1367
Mailing Address - Fax:812-284-8377
Practice Address - Street 1:1701 SPRING ST
Practice Address - Street 2:SUITE A.
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-2930
Practice Address - Country:US
Practice Address - Phone:812-282-1367
Practice Address - Fax:812-284-8377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50002306A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty