Basic Information
Provider Information
NPI: 1104076306
EntityType: 2
ReplacementNPI:  
OrganizationName: PROCARE MEDICAL LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
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Mailing Information
Address1: 2723 S 7TH ST
Address2: STE A
City: TERRE HAUTE
State: IN
PostalCode: 478023558
CountryCode: US
TelephoneNumber: 8122381730
FaxNumber: 8122421565
Practice Location
Address1: 2723 S 7TH ST
Address2: STE A
City: TERRE HAUTE
State: IN
PostalCode: 478023558
CountryCode: US
TelephoneNumber: 8122381730
FaxNumber: 8122421565
Other Information
ProviderEnumerationDate: 09/24/2008
LastUpdateDate: 12/04/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: BITTAR
AuthorizedOfficialFirstName: GEORGE
AuthorizedOfficialMiddleName: B
AuthorizedOfficialTitleorPosition: MEMBER
AuthorizedOfficialTelephone: 8122328164
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208M00000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansHospitalist 

ID Information
IDTypeStateIssuerDescription
200946110A05IN MEDICAID
00000059739201INANTHEMOTHER


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