Provider Demographics
NPI:1285774117
Name:VINCENNES ORTHOPAEDIC SURGERY CLINIC, INC.
Entity type:Organization
Organization Name:VINCENNES ORTHOPAEDIC SURGERY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GLOSSER
Authorized Official - Suffix:I
Authorized Official - Credentials:MS
Authorized Official - Phone:812-882-6972
Mailing Address - Street 1:PO BOX 313
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-0313
Mailing Address - Country:US
Mailing Address - Phone:812-882-6972
Mailing Address - Fax:812-885-2371
Practice Address - Street 1:1019 BAYOU ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-2731
Practice Address - Country:US
Practice Address - Phone:812-882-6972
Practice Address - Fax:812-885-2371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100154180Medicaid
IN100154180Medicaid