=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972576262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERRE HAUTE HEART CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2006
-----------------------------------------------------
Last Update Date | 01/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 E HOSPITAL LN
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47802-4245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-238-1521
-----------------------------------------------------
Fax | 812-232-6335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 E HOSPITAL LN
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47802-4245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-238-1521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PHYSICIAN
-----------------------------------------------------
Name | DR. PRIMO A ANDRES JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 812-238-1521
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 50002041A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------