Basic Information
| Provider Information | |||||||||
| NPI: | 1962586198 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASSOCIATED PHYSICIANS & SURGEONS 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: | 8122423848 | ||||||||
| Practice Location | |||||||||
| Address1: | 1739 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478044002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122320564 | ||||||||
| FaxNumber: | 8122423848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | FOUTY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO/AUTHORIZED REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 8122320564 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ASSOCIATED PHYSICIAN & SURGEONS CLINIC, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0201X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0176835 | 01 | US DEPT OF LABOR | OTHER | ZD3948 | 01 | OPTIMUM CHOICE INC | OTHER |