Provider Demographics
NPI:1336334796
Name:SIGMA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:SIGMA MEDICAL GROUP, LLC
Other - Org Name:RENE S GUTIERREZ, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-449-2410
Mailing Address - Street 1:1415 SALEM ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-4100
Mailing Address - Country:US
Mailing Address - Phone:765-449-2410
Mailing Address - Fax:765-742-8607
Practice Address - Street 1:902 FOXWOOD CT
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-3201
Practice Address - Country:US
Practice Address - Phone:574-583-2495
Practice Address - Fax:574-583-2319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042516A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200495560Medicaid
IN220170Medicare PIN
IN200495560Medicaid