Provider Demographics
NPI:1902313992
Name:SOUTHERN INDIANA COMMUNITY HEALTH CARE, INC
Entity Type:Organization
Organization Name:SOUTHERN INDIANA COMMUNITY HEALTH CARE, INC
Other - Org Name:CRAWFORD COUNTY FAMILY HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:RADCLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-723-7118
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:IN
Mailing Address - Zip Code:47454-0270
Mailing Address - Country:US
Mailing Address - Phone:812-723-7118
Mailing Address - Fax:812-723-7110
Practice Address - Street 1:5604 E WHITE OAK LN
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IN
Practice Address - Zip Code:47140-8413
Practice Address - Country:US
Practice Address - Phone:812-365-3221
Practice Address - Fax:812-365-9502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-29
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200122740AMedicaid