Basic Information
| Provider Information | |||||||||
| NPI: | 1982778080 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE CATH LAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2723 S 7TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478023584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122328164 | ||||||||
| FaxNumber: | 8122421565 | ||||||||
| Practice Location | |||||||||
| Address1: | 2723 S 7TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478023584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122328164 | ||||||||
| FaxNumber: | 8122421565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BITTAR | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8122328164 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.