Basic Information
| Provider Information | |||||||||
| NPI: | 1003996166 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC ASSOCIATES OF SOUTHERN INDIANA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1425 STATE ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | NEW ALBANY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471504909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129452229 | ||||||||
| FaxNumber: | 8129492229 | ||||||||
| Practice Location | |||||||||
| Address1: | 1425 STATE ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | NEW ALBANY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471504909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129452229 | ||||||||
| FaxNumber: | 8129492229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 11/29/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEAN | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8129452229 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100382640 | 05 | IN | MEDICAID |