Provider Demographics
NPI:1871645531
Name:MONTICELLO MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:MONTICELLO MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:TRIBBETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-583-3333
Mailing Address - Street 1:826 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960-1752
Mailing Address - Country:US
Mailing Address - Phone:574-583-3333
Mailing Address - Fax:574-583-4785
Practice Address - Street 1:826 N 6TH ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-1752
Practice Address - Country:US
Practice Address - Phone:574-583-3333
Practice Address - Fax:574-583-4785
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-16
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 261QR1300X
IN207R00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200495560Medicaid
IN2000099180AMedicaid
IN2000099180AMedicaid
IN200495560Medicaid
TN153828Medicare Oscar/Certification
IN220170Medicare PIN