Provider Demographics
NPI: | 1093781171 |
---|---|
Name: | MONTICELLO MEDICAL CENTER, LLC |
Entity Type: | Organization |
Organization Name: | MONTICELLO MEDICAL CENTER, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | CHARLES |
Authorized Official - Middle Name: | R |
Authorized Official - Last Name: | TRIBBETT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 574-583-3333 |
Mailing Address - Street 1: | 826 N 6TH ST |
Mailing Address - Street 2: | |
Mailing Address - City: | MONTICELLO |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 47960-1752 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 574-583-3333 |
Mailing Address - Fax: | 574-583-4785 |
Practice Address - Street 1: | 826 N 6TH ST |
Practice Address - Street 2: | |
Practice Address - City: | MONTICELLO |
Practice Address - State: | IN |
Practice Address - Zip Code: | 47960-1752 |
Practice Address - Country: | US |
Practice Address - Phone: | 574-583-3333 |
Practice Address - Fax: | 574-583-4785 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-02-27 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 01050576A | 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | Group - Multi-Specialty |