Provider Demographics
NPI:1093891251
Name:ASSOCIATED PHYSICIANS & SURGEONS CLINIC, LLC
Entity Type:Organization
Organization Name:ASSOCIATED PHYSICIANS & SURGEONS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:FOUTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-232-0564
Mailing Address - Street 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-232-0564
Mailing Address - Fax:812-242-3848
Practice Address - Street 1:1739 N 4TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-4002
Practice Address - Country:US
Practice Address - Phone:812-232-0564
Practice Address - Fax:812-242-3848
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASSOCIATED PHYSICIANS & SURGEONS CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-31
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0176835OtherUS DEPT OF LABOR
IN100249630SMedicaid
=========025OtherCHAMPUS
=========022OtherTRICARE STANDARD
IN100249630SMedicaid
INCA4474Medicare PIN