Provider Demographics
NPI:1811071970
Name:SOUTHEAST FAMILY PHYSICIANS, PC
Entity type:Organization
Organization Name:SOUTHEAST FAMILY PHYSICIANS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUSSLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-887-1060
Mailing Address - Street 1:5136 E STOP 11 RD
Mailing Address - Street 2:SUITE 30
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-6300
Mailing Address - Country:US
Mailing Address - Phone:317-887-1060
Mailing Address - Fax:317-887-1460
Practice Address - Street 1:5136 E STOP 11 RD
Practice Address - Street 2:SUITE 30
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6300
Practice Address - Country:US
Practice Address - Phone:317-887-1060
Practice Address - Fax:317-887-1460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN139710Medicare PIN