1811071970 NPI number — SOUTHEAST FAMILY PHYSICIANS, 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 1811071970 NPI number — SOUTHEAST FAMILY PHYSICIANS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST FAMILY PHYSICIANS, 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:
1811071970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5136 E STOP 11 RD
Provider Second Line Business Mailing Address:
SUITE 30
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46237-6300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-887-1060
Provider Business Mailing Address Fax Number:
317-887-1460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5136 E STOP 11 RD
Provider Second Line Business Practice Location Address:
SUITE 30
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46237-6300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-887-1060
Provider Business Practice Location Address Fax Number:
317-887-1460
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSLER
Authorized Official First Name:
JANET
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
317-887-1060

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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