Basic Information
| Provider Information | |||||||||
| NPI: | 1518290949 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNION ASSOCIATED PHYSICIANS CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478074214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122320564 | ||||||||
| FaxNumber: | 8122423861 | ||||||||
| Practice Location | |||||||||
| Address1: | 4601 S 7TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478024522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122323281 | ||||||||
| FaxNumber: | 8122353758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2009 | ||||||||
| LastUpdateDate: | 08/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | FOUTY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8122320564 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNION ASSOCIATED PHYSICIANS CLINIC, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | DQ0893 | 01 | IN | RAILROAD MEDICARE | OTHER | 200975660 | 05 | IN | MEDICAID |