Basic Information
| Provider Information | |||||||||
| NPI: | 1023027190 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNION HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | UNION HOSPITAL FAMILY MEDICINE EAST | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4001 WABASH AVE | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478031647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122387711 | ||||||||
| FaxNumber: | 8122387700 | ||||||||
| Practice Location | |||||||||
| Address1: | 4001 WABASH AVE | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478031647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122387711 | ||||||||
| FaxNumber: | 8122387700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REYNOLDS | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHYSICIAN OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8122387915 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 20074840K | 05 | IN | MEDICAID |