Basic Information
| Provider Information | |||||||||
| NPI: | 1407924053 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN INDIANA UROLOGIC CLINIC,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2475 N PARK DR STE 10 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472032215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123769261 | ||||||||
| FaxNumber: | 8123789518 | ||||||||
| Practice Location | |||||||||
| Address1: | 2475 N PARK DR STE 10 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472032215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123769261 | ||||||||
| FaxNumber: | 8123789518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 01/27/2011 | ||||||||
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| AuthorizedOfficialLastName: | MCALEESE | ||||||||
| AuthorizedOfficialFirstName: | KARL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8123769261 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 200328660 | 05 | IN | MEDICAID |