Provider Demographics
NPI:1437475464
Name:WEST MAIN STREET MEDICAL CENTER PC
Entity Type:Organization
Organization Name:WEST MAIN STREET MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:RHEUBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-965-6679
Mailing Address - Street 1:4760 WEST US 40
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374
Mailing Address - Country:US
Mailing Address - Phone:765-965-6679
Mailing Address - Fax:
Practice Address - Street 1:4760 WEST US 40
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374
Practice Address - Country:US
Practice Address - Phone:765-965-6679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034479261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100471010AMedicaid
IN905930Medicare PIN