Healthcare Provider Details

I. General information

NPI: 1891729141
Provider Name (Legal Business Name): PROVIDENCE MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2723 S 7TH ST SUITE A
TERRE HAUTE IN
47802-3558
US

IV. Provider business mailing address

2723 S 7TH ST SUITE A
TERRE HAUTE IN
47802-3558
US

V. Phone/Fax

Practice location:
  • Phone: 812-232-8164
  • Fax: 812-234-6391
Mailing address:
  • Phone: 812-238-1730
  • Fax: 818-242-1565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateIN

VIII. Authorized Official

Name: GEORGE B BITTAR
Title or Position: OWNER
Credential:
Phone: 812-232-8164