1073695243 NPI number — DEARBORN COUNTY SURGERY PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073695243 NPI number — DEARBORN COUNTY SURGERY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEARBORN COUNTY SURGERY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073695243
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
368 BIELBY RD
Provider Second Line Business Mailing Address:
SUITE100
Provider Business Mailing Address City Name:
LAWRENCEBURG
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47025-2774
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-537-5772
Provider Business Mailing Address Fax Number:
812-537-3936

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
368 BIELBY RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LAWRENCEBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47025-1099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-537-5772
Provider Business Practice Location Address Fax Number:
812-537-3936
Provider Enumeration Date:
10/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KROGER
Authorized Official First Name:
BETH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
812-537-5772

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4401214 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100094180 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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