Basic Information
| Provider Information | |||||||||
| NPI: | 1740302827 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN INDIANA COMMUNITY HEALTH CARE, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VALLEY HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 W LONGEST ST | ||||||||
| Address2: | PO BOX 270 | ||||||||
| City: | PAOLI | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474548821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129723944 | ||||||||
| FaxNumber: | 8127237991 | ||||||||
| Practice Location | |||||||||
| Address1: | 9529 W STATE ROAD 56 | ||||||||
| Address2: | |||||||||
| City: | FRENCH LICK | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474329708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129362425 | ||||||||
| FaxNumber: | 8129362599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | RADCLIFF | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8127237118 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| 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 | 100194830 | 05 | IN | MEDICAID | 201168330A | 05 | IN | MEDICAID |