Organization Name: | PROVIDENCE MEDICAL GROUP, LLC |
NPI Number: | 1013087048 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | GEORGE B BITTAR (OWNER) |
Mailing Address: | 115 S Murphy Ave Ste A Brazil |
State: | IN US |
Postal Code: | 478348296 |
Phone Number: | 8124422100 |
Fax Number: | |
NPI Enumeration Date: | 11/08/2006 |
NPI Last Update Date: | 11/01/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QR1300X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IN |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Rural Health |
Taxonomy Definition: |