Provider Demographics
NPI:1912252768
Name:WILLIAM C MASON MD LLC
Entity Type:Organization
Organization Name:WILLIAM C MASON MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-694-0215
Mailing Address - Street 1:2901 OHIO BLVD
Mailing Address - Street 2:SUITE 127
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-2239
Mailing Address - Country:US
Mailing Address - Phone:812-234-8261
Mailing Address - Fax:812-234-8262
Practice Address - Street 1:12238 BAYHILL DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46033-9532
Practice Address - Country:US
Practice Address - Phone:317-694-0215
Practice Address - Fax:317-564-8594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036336A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201095210AMedicaid
INM100075517Medicare PIN