Basic Information
| Provider Information | |||||||||
| NPI: | 1518085661 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERNAL MEDICINE OF SOUTH EAST INDIANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1088 STATE ROAD 229 | ||||||||
| Address2: | |||||||||
| City: | BATESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470066810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129331858 | ||||||||
| FaxNumber: | 8129331968 | ||||||||
| Practice Location | |||||||||
| Address1: | 1088 STATE ROAD 229 | ||||||||
| Address2: | |||||||||
| City: | BATESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470066810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129331858 | ||||||||
| FaxNumber: | 8129331968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 06/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8129331858 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01052054A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1518085661 | 05 | IN | MEDICAID | 200245400B | 05 | IN | MEDICAID |