Provider Demographics
NPI:1982778080
Name:PROVIDENCE CATH LAB
Entity Type:Organization
Organization Name:PROVIDENCE CATH LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BITTAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-232-8164
Mailing Address - Street 1:2723 S 7TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3584
Mailing Address - Country:US
Mailing Address - Phone:812-232-8164
Mailing Address - Fax:812-242-1565
Practice Address - Street 1:2723 S 7TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3584
Practice Address - Country:US
Practice Address - Phone:812-232-8164
Practice Address - Fax:812-242-1565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN193080Medicare ID - Type Unspecified