Healthcare Provider Details

I. General information

NPI: 1104996370
Provider Name (Legal Business Name): THOMAS E SOUTHERN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 GUION RD STE 301
INDIANAPOLIS IN
46222-1672
US

IV. Provider business mailing address

PO BOX 637999
CINCINNATI OH
45263-7999
US

V. Phone/Fax

Practice location:
  • Phone: 317-926-1356
  • Fax: 317-926-1465
Mailing address:
  • Phone: 317-682-2030
  • Fax: 317-644-5060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number01023497A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number01023497A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number01023497A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number01023497A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number01023497A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: