Provider Demographics
NPI:1487765103
Name:SOUTHERN INDIANA AESTHETIC AND PLASTIC SURGERY LLC
Entity type:Organization
Organization Name:SOUTHERN INDIANA AESTHETIC AND PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:LOGAN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-376-8997
Mailing Address - Street 1:2450 N PARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-2292
Mailing Address - Country:US
Mailing Address - Phone:812-376-8997
Mailing Address - Fax:812-373-5323
Practice Address - Street 1:2450 N PARK DR STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-2292
Practice Address - Country:US
Practice Address - Phone:812-376-8997
Practice Address - Fax:812-373-5323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046379A246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical TechnologistGroup - Single Specialty