Basic Information
| Provider Information | |||||||||
| NPI: | 1811317977 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MSO CLINICS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 230 | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478820230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122683318 | ||||||||
| FaxNumber: | 8122684017 | ||||||||
| Practice Location | |||||||||
| Address1: | 2229 MARY SHERMAN DR | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478827633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122683318 | ||||||||
| FaxNumber: | 8122684017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2014 | ||||||||
| LastUpdateDate: | 04/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | FRANKLIN | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8122684311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SULLIVAN COUNTY COMMUNITY HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MSN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 201246990C | 05 | IN | MEDICAID | IN2043 | 01 | IN | MEDICARE PART B | OTHER |