Basic Information
| Provider Information | |||||||||
| NPI: | 1043288111 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOSHEN AMBULATORY CARE CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 WINSTED DR | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465264655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745348794 | ||||||||
| FaxNumber: | 5745343082 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 WINSTED DR | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465264655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745348794 | ||||||||
| FaxNumber: | 5745343082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 06/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | STARNES | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5745348794 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 000000185275 | 01 | IN | ANTHEM BCBS | OTHER | 490004601 | 01 | IN | RAILROAD MEDICARE | OTHER | 200258140 | 05 | IN | MEDICAID |