1457332413 NPI number — SOUTHEASTERN INDIANA GASTROENTEROLOGY

Table of content: (NPI 1457332413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457332413 NPI number — SOUTHEASTERN INDIANA GASTROENTEROLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN INDIANA GASTROENTEROLOGY
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:
1457332413
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/07/2006
NPI Reactivation Date:
12/20/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2630 22ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47201-3702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-372-8680
Provider Business Mailing Address Fax Number:
812-372-9265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2630 22ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47201-3702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-372-8680
Provider Business Practice Location Address Fax Number:
812-372-9265
Provider Enumeration Date:
11/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COLE
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
Authorized Official Title or Position:
PATIENT ACCOUNT REPRESENTATIVE
Authorized Official Telephone Number:
812-372-8680

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  01033813A , 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: 050176P . This is a "SIHO PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000317541 . This is a "ICHIA PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000317541 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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