Provider Demographics
NPI:1548357775
Name:FAMILY MEDICAL ASSOCIATES P C
Entity type:Organization
Organization Name:FAMILY MEDICAL ASSOCIATES P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DHAMY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIVAMOHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-595-0280
Mailing Address - Street 1:1428 N GARDNER ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-8720
Mailing Address - Country:US
Mailing Address - Phone:812-752-4001
Mailing Address - Fax:812-752-4654
Practice Address - Street 1:1428 N GARDNER ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-8720
Practice Address - Country:US
Practice Address - Phone:812-752-4001
Practice Address - Fax:812-752-4654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055482A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200447040AMedicaid
=========OtherTAX ID
IN200447040AMedicaid
=========OtherTAX ID