Basic Information
| Provider Information | |||||||||
| NPI: | 1902313992 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN INDIANA COMMUNITY HEALTH CARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CRAWFORD COUNTY FAMILY HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 270 | ||||||||
| Address2: | |||||||||
| City: | PAOLI | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474540270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127237118 | ||||||||
| FaxNumber: | 8127237110 | ||||||||
| Practice Location | |||||||||
| Address1: | 5604 E WHITE OAK LN | ||||||||
| Address2: | |||||||||
| City: | MARENGO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471408413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123653221 | ||||||||
| FaxNumber: | 8123659502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2017 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RADCLIFF | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8127237118 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 200122740A | 05 | IN | MEDICAID |