Basic Information
| Provider Information | |||||||||
| NPI: | 1811074982 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENRY COUNTY URGENT CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 337 | ||||||||
| Address2: | |||||||||
| City: | NEW CASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473620337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655211366 | ||||||||
| FaxNumber: | 7655211555 | ||||||||
| Practice Location | |||||||||
| Address1: | 113 SOUTH MEMORIAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | NEW CASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473624947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655211366 | ||||||||
| FaxNumber: | 7655211555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 12/07/2009 | ||||||||
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| AuthorizedOfficialLastName: | JANSSEN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7655211508 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200406810A | 05 | IN | MEDICAID | 000000224292 | 01 | IN | ANTHEM | OTHER |