Provider Demographics
NPI:1003849399
Name:MONTICELLO EMERGENCY CARE, LLC
Entity Type:Organization
Organization Name:MONTICELLO EMERGENCY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-446-0170
Mailing Address - Street 1:3500 STATE ROAD 38 E STE 300
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5167
Mailing Address - Country:US
Mailing Address - Phone:765-446-0170
Mailing Address - Fax:855-506-7359
Practice Address - Street 1:4011 S MONROE MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-8000
Practice Address - Country:US
Practice Address - Phone:812-825-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300065600Medicaid
INDD5512OtherRAIL ROAD MEDICARE
INDD5512OtherRAIL ROAD MEDICARE