Healthcare Provider Details

I. General information

NPI: 1457332413
Provider Name (Legal Business Name): SOUTHEASTERN INDIANA GASTROENTEROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date: 03/07/2006
Reactivation Date: 12/20/2006

III. Provider practice location address

2630 22ND ST
COLUMBUS IN
47201-3702
US

IV. Provider business mailing address

2630 22ND ST
COLUMBUS IN
47201-3702
US

V. Phone/Fax

Practice location:
  • Phone: 812-372-8680
  • Fax: 812-372-9265
Mailing address:
  • Phone: 812-372-8680
  • Fax: 812-372-9265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number01033813A
License Number StateIN

VIII. Authorized Official

Name: DIANE COLE
Title or Position: PATIENT ACCOUNT REPRESENTATIVE
Credential: BILLING OFFICE
Phone: 812-372-8680