Provider Demographics
NPI:1770626152
Name:SOUTHERN INDIANA FAMILY PRACTICE CENTER PC
Entity type:Organization
Organization Name:SOUTHERN INDIANA FAMILY PRACTICE CENTER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:L
Authorized Official - Last Name:REID-RENNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-339-6744
Mailing Address - Street 1:3209 W FULLERTON PIKE
Mailing Address - Street 2:STE A
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4060
Mailing Address - Country:US
Mailing Address - Phone:812-339-6744
Mailing Address - Fax:812-671-9113
Practice Address - Street 1:3209 W FULLERTON PIKE
Practice Address - Street 2:STE A
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4060
Practice Address - Country:US
Practice Address - Phone:812-339-6744
Practice Address - Fax:812-671-9113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002130A363L00000X
IN01055670A305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200367600AMedicaid
IN188690Medicare ID - Type Unspecified
IN200367600AMedicaid