=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194045849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNION ASSOCIATED PHYSICIANS CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2010
-----------------------------------------------------
Last Update Date | 08/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 N 2ND ST
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62441-1010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-826-2361
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 221 S 6TH ST
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47807-4214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-242-3274
-----------------------------------------------------
Fax | 812-242-3861
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED REPRESENTATIVE
-----------------------------------------------------
Name | MICHAEL P FOUTY
-----------------------------------------------------
Credential | CFO
-----------------------------------------------------
Telephone | 812-242-3274
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------