Basic Information
| Provider Information | |||||||||
| NPI: | 1093781171 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTICELLO MEDICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 826 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479601752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745833333 | ||||||||
| FaxNumber: | 5745834785 | ||||||||
| Practice Location | |||||||||
| Address1: | 826 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479601752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745833333 | ||||||||
| FaxNumber: | 5745834785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | TRIBBETT | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5745833333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 01050576A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.