| Organization Name: | PROVIDENCE MEDICAL GROUP, LLC |
| NPI Number: | 1538201421 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | CHARLES R FRENCH (DIRECTOR) |
| Mailing Address: | 1207 E National Ave Brazil |
| State: | IN US |
| Postal Code: | 478342717 |
| Phone Number: | 8124462551 |
| Fax Number: | 8124462810 |
| NPI Enumeration Date: | 02/14/2007 |
| NPI Last Update Date: | 03/21/2014 |
| 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: | |