Provider Demographics
NPI:1891729141
Name:PROVIDENCE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BITTAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-232-8164
Mailing Address - Street 1:2723 S 7TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3558
Mailing Address - Country:US
Mailing Address - Phone:812-238-1730
Mailing Address - Fax:818-242-1565
Practice Address - Street 1:2723 S 7TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3558
Practice Address - Country:US
Practice Address - Phone:812-232-8164
Practice Address - Fax:812-234-6391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCG4466OtherRAILROAD MEDICARE
INCH9272OtherRAILROAD MEDICARE
IN200261130Medicaid
IN200398780Medicaid
IL212671Medicare PIN
INCG4466Medicare PIN
IN5647840004Medicare NSC
INCH9272Medicare PIN
IN162190Medicare PIN
INCH9272OtherRAILROAD MEDICARE
INCG4466OtherRAILROAD MEDICARE
IN200398780Medicaid