Healthcare Provider Details

I. General information

NPI: 1770626152
Provider Name (Legal Business Name): SOUTHERN INDIANA FAMILY PRACTICE CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 W FULLERTON PIKE STE A
BLOOMINGTON IN
47403-4060
US

IV. Provider business mailing address

3209 W FULLERTON PIKE STE A
BLOOMINGTON IN
47403-4060
US

V. Phone/Fax

Practice location:
  • Phone: 812-339-6744
  • Fax: 812-671-9113
Mailing address:
  • Phone: 812-339-6744
  • Fax: 812-671-9113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number01055670A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71002130A
License Number StateIN

VIII. Authorized Official

Name: KAREN L. REID-RENNER
Title or Position: OWNER
Credential: MD
Phone: 812-339-6744