Provider Demographics
NPI:1265524383
Name:CENTRAL INDIANA OB/GYN, LLC
Entity type:Organization
Organization Name:CENTRAL INDIANA OB/GYN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:E
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-729-4903
Mailing Address - Street 1:3111 W JACKSON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-4371
Mailing Address - Country:US
Mailing Address - Phone:765-288-2200
Mailing Address - Fax:765-288-0913
Practice Address - Street 1:3111 W JACKSON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-4371
Practice Address - Country:US
Practice Address - Phone:765-288-2200
Practice Address - Fax:765-288-0913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01060775AOtherIN MEDICAL LICENSE
IN200522530Medicaid
IN01060775BOtherIN CDS
IN01060775BOtherIN CDS