1952462301 NPI number — TERRE HAUTE PULMONARY & PEDIATRIC CLINIC, LLC

Table of content: (NPI 1952462301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952462301 NPI number — TERRE HAUTE PULMONARY & PEDIATRIC CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERRE HAUTE PULMONARY & PEDIATRIC CLINIC, LLC
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:
GREENCASTLE CLINIC
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:
1952462301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
06/19/2007
NPI Reactivation Date:
04/30/2008

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4525 S SPRINGHILL JCT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TERRE HAUTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47802-4563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-234-6053
Provider Business Mailing Address Fax Number:
812-234-1722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1542 S BLOOMINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENCASTLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46135-2212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-234-6053
Provider Business Practice Location Address Fax Number:
812-234-1722
Provider Enumeration Date:
12/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BHUPTANI
Authorized Official First Name:
TRUPTI
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CO OWNER MD
Authorized Official Telephone Number:
812-234-6053

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  01038772A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RP1001X , with the licence number: 01052847A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 71001110A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200391150I , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".