Basic Information
| Provider Information | |||||||||
| NPI: | 1871645531 | ||||||||
| 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: | 01/16/2007 | ||||||||
| LastUpdateDate: | 08/02/2011 | ||||||||
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| AuthorizedOfficialLastName: | TRIBBETT | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5745833333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NO | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | IN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | IN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 200495560 | 05 | IN | MEDICAID | 2000099180A | 05 | IN | MEDICAID |