Provider Demographics
NPI:1184719155
Name:MEDICAL OF DUBOIS A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MEDICAL OF DUBOIS A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:FIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-634-6824
Mailing Address - Street 1:695 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-3602
Mailing Address - Country:US
Mailing Address - Phone:812-634-6824
Mailing Address - Fax:812-481-1056
Practice Address - Street 1:695 3RD AVE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-3602
Practice Address - Country:US
Practice Address - Phone:812-634-6824
Practice Address - Fax:812-848-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025667208D00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDF6038OtherMEDICARE RAILROAD
IN000000310221OtherANTHEM
INM100061947Medicare PIN
IN000000310221OtherANTHEM