Basic Information
| Provider Information | |||||||||
| NPI: | 1932225372 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TULIP TREE HEALTH SERVICES OF GIBSON COUNTY, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TULIP TREE FAMILY HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 123 N MCCREARY ST | ||||||||
| Address2: | |||||||||
| City: | FORT BRANCH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476481313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127531039 | ||||||||
| FaxNumber: | 8127531122 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 N MCCREARY ST | ||||||||
| Address2: | |||||||||
| City: | FORT BRANCH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127531039 | ||||||||
| FaxNumber: | 8127531122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 03/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GEORGES | ||||||||
| AuthorizedOfficialFirstName: | KRISTINE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8127531039 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 207Q00000X | 02000610 | IN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 200248220A | 05 | IN | MEDICAID |