Provider Demographics
NPI: | 1013953983 |
---|---|
Name: | INDIANA UNIVERSITY HEALTH SOUTHERN INDIANA PHYSICIANS, LLC |
Entity Type: | Organization |
Organization Name: | INDIANA UNIVERSITY HEALTH SOUTHERN INDIANA PHYSICIANS, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CFO |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | MICHAEL |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | CRAIG |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 812-353-9171 |
Mailing Address - Street 1: | 250 N SHADELAND AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | INDIANAPOLIS |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46219-4959 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 888-484-3258 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2651 E DISCOVERY PKWY |
Practice Address - Street 2: | |
Practice Address - City: | BLOOMINGTON |
Practice Address - State: | IN |
Practice Address - Zip Code: | 47408-9059 |
Practice Address - Country: | US |
Practice Address - Phone: | 812-353-5252 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | INDIANA UNIVERSITY HEALTH BLOOMINGTON INC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2006-06-21 |
Last Update Date: | 2024-02-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | Group - Multi-Specialty |
No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
No | 367500000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 100433840 | Medicaid | |
CI4187 | Other | RAILROAD MEDICARE ID | |
CI4187 | Other | RAILROAD MEDICARE ID |