Basic Information
| Provider Information | |||||||||
| NPI: | 1003849399 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTICELLO EMERGENCY CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3652 ROME DR | ||||||||
| Address2: | STE A | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479054465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654460170 | ||||||||
| FaxNumber: | 2604078000 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479608182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745837111 | ||||||||
| FaxNumber: | 2604078004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 04/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | O'BRIEN | ||||||||
| AuthorizedOfficialFirstName: | ERIKA | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO-CFO | ||||||||
| AuthorizedOfficialTelephone: | 7654460170 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200240540A | 05 | IN | MEDICAID | DD5512 | 01 | IN | RAIL ROAD MEDICARE | OTHER |