Provider Demographics
NPI:1275536195
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 AND CHIEF MEDICAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEPOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-244-0100
Mailing Address - Street 1:PO BOX 9359
Mailing Address - Street 2:634 BEECH STREET
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47808-9359
Mailing Address - Country:US
Mailing Address - Phone:812-244-0100
Mailing Address - Fax:812-232-1517
Practice Address - Street 1:1606 N 7TH STREET
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-2706
Practice Address - Country:US
Practice Address - Phone:812-244-0100
Practice Address - Fax:812-232-1517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50000920A291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100453080AMedicaid
IN200131840AMedicaid
IN100284650AMedicaid
IN100468870AMedicaid
IN100284700Medicaid
IN100468890AMedicaid
IN100284610AMedicaid
IN203700Medicare ID - Type Unspecified
IL205008Medicare ID - Type Unspecified
IN100284610AMedicaid
IN608590Medicare ID - Type Unspecified
IN200131840AMedicaid
IN100468870AMedicaid
IN983080Medicare ID - Type Unspecified
IN983190Medicare ID - Type Unspecified
IN983230Medicare ID - Type Unspecified
IN100468890AMedicaid