Provider Demographics
NPI:1790843829
Name:SOUTHERN INDIANA DIABETES AND ENDOCRINOLOGY PC
Entity type:Organization
Organization Name:SOUTHERN INDIANA DIABETES AND ENDOCRINOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:VASTI
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-949-5700
Mailing Address - Street 1:1008 FOX HUNTERS PT
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-9251
Mailing Address - Country:US
Mailing Address - Phone:812-949-5700
Mailing Address - Fax:812-949-5979
Practice Address - Street 1:2019 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4921
Practice Address - Country:US
Practice Address - Phone:812-949-5700
Practice Address - Fax:812-949-5979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200332950AMedicaid
KY65935603Medicaid
IN185170Medicare PIN
KY65935603Medicaid