Provider Demographics
NPI:1871799510
Name:TERRE HAUTE SURGICAL CENTER LLC
Entity type:Organization
Organization Name:TERRE HAUTE SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER, AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:227 E MCCALLISTER DR
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4248
Mailing Address - Country:US
Mailing Address - Phone:812-234-4315
Mailing Address - Fax:812-234-4381
Practice Address - Street 1:227 E MCCALLISTER DR
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4248
Practice Address - Country:US
Practice Address - Phone:812-234-4315
Practice Address - Fax:812-234-4381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07-005650-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INZQ9000Medicare PIN
IN15C0001158Medicare Oscar/Certification