Provider Demographics
NPI:1770084261
Name:PHYSICIANS MEDICAL CENTER LLC
Entity type:Organization
Organization Name:PHYSICIANS MEDICAL CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-590-6936
Mailing Address - Street 1:3626 GRANT LINE RD STE 205
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-2584
Mailing Address - Country:US
Mailing Address - Phone:812-590-6936
Mailing Address - Fax:812-913-4338
Practice Address - Street 1:2108 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4923
Practice Address - Country:US
Practice Address - Phone:812-670-4305
Practice Address - Fax:812-725-1210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty