Healthcare Provider Details

I. General information

NPI: 1518085661
Provider Name (Legal Business Name): INTERNAL MEDICINE OF SOUTH EAST INDIANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1088 STATE ROAD 229
BATESVILLE IN
47006-6810
US

IV. Provider business mailing address

1088 STATE ROAD 229
BATESVILLE IN
47006-6810
US

V. Phone/Fax

Practice location:
  • Phone: 812-933-1858
  • Fax: 812-933-1968
Mailing address:
  • Phone: 812-933-1858
  • Fax: 812-933-1968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01052054A
License Number StateIN

VIII. Authorized Official

Name: MIKE ROBERTSON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 812-933-1858