Provider Demographics
NPI:1164749503
Name:TERRE HAUTE MEDICAL LABORATORY, INC.
Entity Type:Organization
Organization Name:TERRE HAUTE MEDICAL LABORATORY, INC.
Other - Org Name:MEDLAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:DEPOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-244-0100
Mailing Address - Street 1:634 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-2760
Mailing Address - Country:US
Mailing Address - Phone:812-244-0100
Mailing Address - Fax:812-244-0096
Practice Address - Street 1:890 RIDGELAWN RD
Practice Address - Street 2:SUITE A
Practice Address - City:MARTINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62442
Practice Address - Country:US
Practice Address - Phone:812-244-0100
Practice Address - Fax:812-244-0096
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TERRE HAUTE MEDICAL LABORATORY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50000920A291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory