Healthcare Provider Details

I. General information

NPI: 1639164999
Provider Name (Legal Business Name): CREEKSIDE OBGYN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 N LEBANON ST STE 208
LEBANON IN
46052-8612
US

IV. Provider business mailing address

2505 N LEBANON ST STE 208
LEBANON IN
46052-8612
US

V. Phone/Fax

Practice location:
  • Phone: 765-485-8444
  • Fax: 765-483-7365
Mailing address:
  • Phone: 765-485-8444
  • Fax: 765-483-7365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number50004241A
License Number StateIN

VIII. Authorized Official

Name: SANDRA L ANDERSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 765-483-7361