Provider Demographics
NPI:1891887386
Name:UROLOGY OF SOUTHEASTERN IN
Entity type:Organization
Organization Name:UROLOGY OF SOUTHEASTERN IN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:JARVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-933-0990
Mailing Address - Street 1:108 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47006-1280
Mailing Address - Country:US
Mailing Address - Phone:812-933-0990
Mailing Address - Fax:812-933-0784
Practice Address - Street 1:108 N ELM ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:IN
Practice Address - Zip Code:47006-1280
Practice Address - Country:US
Practice Address - Phone:812-933-0990
Practice Address - Fax:812-933-0784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058527208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN701700Medicare PIN