Healthcare Provider Details

I. General information

NPI: 1417921933
Provider Name (Legal Business Name): SOUTHERN INDIANA PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 02/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 S LANDMARK AVE
BLOOMINGTON IN
47403-5001
US

IV. Provider business mailing address

350 S LANDMARK AVE
BLOOMINGTON IN
47403-5001
US

V. Phone/Fax

Practice location:
  • Phone: 812-335-2434
  • Fax: 812-335-7604
Mailing address:
  • Phone: 812-335-2434
  • Fax: 812-335-7604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL CRAIG
Title or Position: CFO
Credential:
Phone: 812-353-9554