Basic Information
Provider Information | |||||||||
NPI: | 1891729141 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROVIDENCE MEDICAL GROUP LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2723 S 7TH ST | ||||||||
Address2: | SUITE A | ||||||||
City: | TERRE HAUTE | ||||||||
State: | IN | ||||||||
PostalCode: | 478023558 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8122381730 | ||||||||
FaxNumber: | 8182421565 | ||||||||
Practice Location | |||||||||
Address1: | 2723 S 7TH ST | ||||||||
Address2: | SUITE A | ||||||||
City: | TERRE HAUTE | ||||||||
State: | IN | ||||||||
PostalCode: | 478023558 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8122328164 | ||||||||
FaxNumber: | 8122346391 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 10/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BITTAR | ||||||||
AuthorizedOfficialFirstName: | GEORGE | ||||||||
AuthorizedOfficialMiddleName: | B | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 8122328164 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   | IN | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | CG4466 | 01 | IN | RAILROAD MEDICARE | OTHER | CH9272 | 01 | IN | RAILROAD MEDICARE | OTHER | 200261130 | 05 | IN |   | MEDICAID | 200398780 | 05 | IN |   | MEDICAID |