Provider Demographics
NPI:1104996370
Name:SOUTHERN, THOMAS E (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:SOUTHERN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 637999
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-7999
Mailing Address - Country:US
Mailing Address - Phone:317-682-2030
Mailing Address - Fax:317-644-5060
Practice Address - Street 1:3520 GUION RD
Practice Address - Street 2:STE 301
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-1672
Practice Address - Country:US
Practice Address - Phone:317-926-1356
Practice Address - Fax:317-926-1465
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023497A208200000X, 2082S0099X, 2082S0105X, 2086S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000762785OtherBCBS
IN100073340AMedicaid
INM400068635Medicare PIN