Healthcare Provider Details

I. General information

NPI: 1972914539
Provider Name (Legal Business Name): SYCAMORE SPRINGS PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2014
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 PARK EAST BLVD
LAFAYETTE IN
47905-0785
US

IV. Provider business mailing address

833 PARK EAST BLVD
LAFAYETTE IN
47905-0785
US

V. Phone/Fax

Practice location:
  • Phone: 765-743-4400
  • Fax: 765-743-4411
Mailing address:
  • Phone: 765-743-4400
  • Fax: 765-743-4411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GREG MILLER
Title or Position: EVP, CFO
Credential:
Phone: 412-588-3546