Provider Demographics
NPI:1811075286
Name:HUNTINGBURG MEDICAL CENTER, INC
Entity type:Organization
Organization Name:HUNTINGBURG MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:GWENDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRECKLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:812-683-4900
Mailing Address - Street 1:1706 MEDICAL ARTS DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:HUNTINGBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47542-9049
Mailing Address - Country:US
Mailing Address - Phone:812-683-4900
Mailing Address - Fax:812-683-3206
Practice Address - Street 1:1706 MEDICAL ARTS DR
Practice Address - Street 2:SUITE 3
Practice Address - City:HUNTINGBURG
Practice Address - State:IN
Practice Address - Zip Code:47542-9049
Practice Address - Country:US
Practice Address - Phone:812-683-4900
Practice Address - Fax:812-683-3206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002504207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200235580Medicaid
IN200235580Medicaid
IN247960Medicare PIN
IN=========OtherANTHEM PROVIDER NUMBER