Healthcare Provider Details

I. General information

NPI: 1972618775
Provider Name (Legal Business Name): ANDREW TAD MCDONALD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 N 5TH ST
TERRE HAUTE IN
47804-4010
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 812-242-3005
  • Fax: 812-242-3054
Mailing address:
  • Phone: 812-242-3005
  • Fax: 812-242-3054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number36113741
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number01062210A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: