Basic Information
| Provider Information | |||||||||
| NPI: | 1447235619 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN INDIANA PATHOLOGISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 WEST SECOND STREET | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474022317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123366821 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2005 | ||||||||
| LastUpdateDate: | 03/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | STEVENS | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED SIGNER | ||||||||
| AuthorizedOfficialTelephone: | 8123366821 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 207ZP0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 200341600A | 05 | IN | MEDICAID |