Healthcare Provider Details

I. General information

NPI: 1861922247
Provider Name (Legal Business Name): STEPHEN A WURSTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 N 7TH ST STE 200
TERRE HAUTE IN
47807-1061
US

IV. Provider business mailing address

221 S 6TH ST
TERRE HAUTE IN
47807-4214
US

V. Phone/Fax

Practice location:
  • Phone: 812-238-7631
  • Fax: 812-238-7003
Mailing address:
  • Phone: 812-242-3157
  • Fax: 812-242-3861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01083371A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01083371A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: