Provider Demographics
NPI:1457607046
Name:G REX STROUD JR MD PC
Entity Type:Organization
Organization Name:G REX STROUD JR MD PC
Other - Org Name:STROUD MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:G
Authorized Official - Middle Name:REX
Authorized Official - Last Name:STROUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-254-4399
Mailing Address - Street 1:PO BOX 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-473-0181
Mailing Address - Fax:812-473-5822
Practice Address - Street 1:201 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-2970
Practice Address - Country:US
Practice Address - Phone:812-254-4399
Practice Address - Fax:812-254-4473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-01
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057059A207Q00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN15D2044671OtherCLIA
IN201087090AMedicaid
IN15D2044671OtherCLIA