Healthcare Provider Details

I. General information

NPI: 1043204944
Provider Name (Legal Business Name): AMBULATORY CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CIRCLE FRONT DR
EVANSVILLE IN
47715-7196
US

IV. Provider business mailing address

300 CIRCLE FRONT DR
EVANSVILLE IN
47715-7196
US

V. Phone/Fax

Practice location:
  • Phone: 812-475-1800
  • Fax: 812-475-1801
Mailing address:
  • Phone: 812-475-1800
  • Fax: 812-475-1801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number3891
License Number StateIN

VIII. Authorized Official

Name: ANDREA JARVIS
Title or Position: CONTROLLER
Credential: MBA
Phone: 812-475-1000