Provider Demographics
NPI:1699857649
Name:ASSOCIATED PHYSICIANS & SURGEONS CLINIC, LLC
Entity Type:Organization
Organization Name:ASSOCIATED PHYSICIANS & SURGEONS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:FOUTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-232-0564
Mailing Address - Street 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-232-0564
Mailing Address - Fax:812-242-3848
Practice Address - Street 1:890 RIDGELAWN RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62442-0399
Practice Address - Country:US
Practice Address - Phone:812-232-0564
Practice Address - Fax:812-242-3848
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASSOCIATED PHYSICIANS & SURGEONS CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-19
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCE0949Medicare PIN
IL387250Medicare PIN