Basic Information
| Provider Information | |||||||||
| NPI: | 1457332413 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHEASTERN INDIANA GASTROENTEROLOGY | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2630 22ND ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472013702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123728680 | ||||||||
| FaxNumber: | 8123729265 | ||||||||
| Practice Location | |||||||||
| Address1: | 2630 22ND ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472013702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123728680 | ||||||||
| FaxNumber: | 8123729265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/07/2006 | ||||||||
| NPIReactivationDate: | 12/20/2006 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLE | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT ACCOUNT REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 8123728680 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BILLING OFFICE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 01033813A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 050176P | 01 | IN | SIHO PROVIDER NUMBER | OTHER | 000000317541 | 01 | IN | ICHIA PROVIDER NUMBER | OTHER | 000000317541 | 01 | IN | ANTHEM | OTHER |