Organization
PROVIDENCE MEDICAL GROUP LLC
Active
Organization
PROVIDENCE MEDICAL GROUP LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GEORGE B BITTAR (OWNER)
(812) 232-8164
Entity
Organization
Contact information
Practice address
2723 S 7TH ST, SUITE A, TERRE HAUTE, IN 47802-3558
(812) 232-8164
(812) 234-6391
Mailing address
2723 S 7TH ST, SUITE A, TERRE HAUTE, IN 47802-3558
(812) 238-1730
(818) 242-1565
Taxonomy
Speciality
Code
Description
License number
State
261QM1300X
Multi-Specialty Clinic/Center
Primary
—
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200261130
—
IN
05
—
200398780
—
IN
01
—
CG4466
RAILROAD MEDICARE
IN
01
—
CH9272
RAILROAD MEDICARE
IN
Enumeration date
07/11/2006
Last updated
10/09/2020
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