Provider Demographics
NPI:1831110170
Name:SOUTHERN INDIANA ENDOSCOPY, LLC
Entity Type:Organization
Organization Name:SOUTHERN INDIANA ENDOSCOPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:H
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-945-0145
Mailing Address - Street 1:825 UNIVERSITY WOODS DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-2427
Mailing Address - Country:US
Mailing Address - Phone:812-945-0145
Mailing Address - Fax:812-949-5443
Practice Address - Street 1:2630 GRANT LINE RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4053
Practice Address - Country:US
Practice Address - Phone:812-945-0145
Practice Address - Fax:812-206-7089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN060028691261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200358660AMedicaid
INZM2090Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER