Healthcare Provider Details

I. General information

NPI: 1609120344
Provider Name (Legal Business Name): TERRE HAUTE SURGICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2012
Last Update Date: 03/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 E MCCALLISTER DR
TERRE HAUTE IN
47802-4248
US

IV. Provider business mailing address

227 E MCCALLISTER DR
TERRE HAUTE IN
47802-4248
US

V. Phone/Fax

Practice location:
  • Phone: 812-234-4315
  • Fax: 812-234-4381
Mailing address:
  • Phone: 812-234-4321
  • Fax: 812-234-4381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: JENETHA D MORAN
Title or Position: OFFICER / AUTHORIZED OFFICIAL
Credential:
Phone: 972-763-3893