MEDICARE: THOMAS E SOUTHERN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	01023497A	IN
2	2082S0099X	Plastic Surgery Within the Head and Neck (Plastic Surgery) Physician	01023497A	IN
3	2082S0105X	Surgery of the Hand (Plastic Surgery) Physician	01023497A	IN
4	2086S0105X	Surgery of the Hand (Surgery) Physician	01023497A	IN
5	2086S0122X	Plastic and Reconstructive Surgery Physician	01023497A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000762785	OTHER	IN	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104996370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS E SOUTHERN MD

Provider Business Mailing Address
First Line	:	PO BOX 637999
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-7999
Country	:	US
Telephone Number	:	317-682-2030
Fax Number	:	317-644-5060

Provider Business Practice Location Address
First Line	:	3520 GUION RD
Second Line	:	STE 301
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46222-1672
Country	:	US
Telephone Number	:	317-926-1356
Fax Number	:	317-926-1465

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	03/19/2013

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Directions to “ THOMAS E SOUTHERN MD” Practice Location

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