Provider Demographics
NPI:1013902394
Name:SURGICAL ASSOCIATES SOUTHERN INDIANA, PSC
Entity Type:Organization
Organization Name:SURGICAL ASSOCIATES SOUTHERN INDIANA, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MACMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-282-0637
Mailing Address - Street 1:301 GORDON GUTMANN BLVD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3739
Mailing Address - Country:US
Mailing Address - Phone:812-282-0637
Mailing Address - Fax:812-283-6330
Practice Address - Street 1:301 GORDON GUTMANN BLVD
Practice Address - Street 2:SUITE 401
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3764
Practice Address - Country:US
Practice Address - Phone:812-282-0637
Practice Address - Fax:812-283-6330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50003241A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200105360AMedicaid
IN50003241AOtherMED. CORP. CERTIFICATION
IN200105360AMedicaid