Provider Demographics
NPI:1811074982
Name:HENRY COUNTY URGENT CARE LLC
Entity type:Organization
Organization Name:HENRY COUNTY URGENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:F
Authorized Official - Last Name:JANSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-521-1508
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:47362-0337
Mailing Address - Country:US
Mailing Address - Phone:765-521-1366
Mailing Address - Fax:765-521-1555
Practice Address - Street 1:113 SOUTH MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:IN
Practice Address - Zip Code:47362-4947
Practice Address - Country:US
Practice Address - Phone:765-521-1366
Practice Address - Fax:765-521-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200406810AMedicaid
IN000000224292OtherANTHEM
IN192570Medicare ID - Type Unspecified