Provider Demographics
NPI:1225254808
Name:TERRE HAUTE NEUROSURGICAL AND SPINE CLINIC, LLC
Entity Type:Organization
Organization Name:TERRE HAUTE NEUROSURGICAL AND SPINE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:G
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:812-238-4900
Mailing Address - Street 1:1530 N 7TH ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-1057
Mailing Address - Country:US
Mailing Address - Phone:812-238-4900
Mailing Address - Fax:812-239-4921
Practice Address - Street 1:1530 N 7TH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1057
Practice Address - Country:US
Practice Address - Phone:812-238-4900
Practice Address - Fax:812-239-4921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057579A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000295844OtherBLUECROSS
IN200452000AMedicaid
IN000000295844OtherBLUECROSS
IN5446840001Medicare NSC
IN209000Medicare PIN