Healthcare Provider Details

I. General information

NPI: 1619224979
Provider Name (Legal Business Name): SOUTHERN INDIANA PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2012
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 S CHESTNUT ST
SEYMOUR IN
47274-2370
US

IV. Provider business mailing address

410 S CHESTNUT ST
SEYMOUR IN
47274-2370
US

V. Phone/Fax

Practice location:
  • Phone: 812-378-7000
  • Fax:
Mailing address:
  • Phone: 812-378-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01032854A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1040351
License Number StateIN

VIII. Authorized Official

Name: MR. RICHARD KRAMER
Title or Position: VICE PRESIDENT FINANCE
Credential:
Phone: 812-378-7000