1639772353 NPI number — SOUTHERN INDIANA COMMUNITY HEALTH CARE, INC

Table of content: (NPI 1639772353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639772353 NPI number — SOUTHERN INDIANA COMMUNITY HEALTH CARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN INDIANA COMMUNITY HEALTH CARE, INC
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:
1639772353
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 270
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAOLI
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47454-0270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-723-3944
Provider Business Mailing Address Fax Number:
812-723-7989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 N JIM DAY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47167-7219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-723-3944
Provider Business Practice Location Address Fax Number:
812-723-7989
Provider Enumeration Date:
11/17/2020

Additional Information

Authorized Official

Authorized Official Last Name:
RADCLIFF
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
812-723-3944

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300017230A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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