Provider Demographics
NPI:1487640140
Name:INDIANA WEST, PC
Entity Type:Organization
Organization Name:INDIANA WEST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:STALLCOP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-232-6673
Mailing Address - Street 1:4601 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4522
Mailing Address - Country:US
Mailing Address - Phone:812-232-6673
Mailing Address - Fax:812-232-1519
Practice Address - Street 1:4601 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4522
Practice Address - Country:US
Practice Address - Phone:812-232-6673
Practice Address - Fax:812-232-1519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50003589174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN607120Medicare ID - Type Unspecified