1760461339 NPI number — SOUTH CENTRAL ORAL & MAXILLOFACIAL SURGERY, LLC

Table of content: (NPI 1760461339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760461339 NPI number — SOUTH CENTRAL ORAL & MAXILLOFACIAL SURGERY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH CENTRAL ORAL & MAXILLOFACIAL SURGERY, LLC
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:
1760461339
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2911 E COVENANTER DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47401-6320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-333-2614
Provider Business Mailing Address Fax Number:
812-333-4594

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2911 E COVENANTER DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47401-6320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-333-2614
Provider Business Practice Location Address Fax Number:
812-333-4594
Provider Enumeration Date:
01/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PLISKE
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
812-333-2614

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  12008000/12009582 , 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)





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