Basic Information
| Provider Information | |||||||||
| NPI: | 1700909348 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN INDIANA COMMUNITY HEALTH CARE, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CRAWFORD COUNTY FAMILY HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 420 W LONGEST ST | ||||||||
| Address2: | PO BOX 270 | ||||||||
| City: | PAOLI | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474548821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127237119 | ||||||||
| FaxNumber: | 8127235292 | ||||||||
| Practice Location | |||||||||
| Address1: | 5604 E WHITE OAK LN | ||||||||
| Address2: | |||||||||
| City: | MARENGO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471408413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123653221 | ||||||||
| FaxNumber: | 8123659502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | TONYA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8127237119 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPB | ||||||||
| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200122740A | 05 | IN | MEDICAID | CI7706 | 01 | IN | MEDICARE ID | OTHER |