Basic Information
| Provider Information | |||||||||
| NPI: | 1194824748 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST INDIANA OBSTETRICS AND GYNECOLOGY,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2451 INTELLIPLEX DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173980193 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2451 INTELLIPLEX DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173980193 | ||||||||
| FaxNumber: | 3174212016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | HORNER | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3173923211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.