1275536195 NPI number — TERRE HAUTE MEDICAL LABORATORY, INC

Table of content: (NPI 1275536195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275536195 NPI number — TERRE HAUTE MEDICAL LABORATORY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERRE HAUTE MEDICAL LABORATORY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MEDLAB
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275536195
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9359
Provider Second Line Business Mailing Address:
634 BEECH STREET
Provider Business Mailing Address City Name:
TERRE HAUTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47808-9359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-244-0100
Provider Business Mailing Address Fax Number:
812-232-1517

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1606 N 7TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47804-2706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-244-0100
Provider Business Practice Location Address Fax Number:
812-232-1517
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DEPOND
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PRESIDENT AND CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
812-244-0100

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  50000920A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100453080A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200131840A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100284650A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100468870A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100284700 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100468890A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100284610A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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