Provider Demographics
NPI:1316958549
Name:WABASH VALLEY UROLOGICAL ASSOC INC
Entity type:Organization
Organization Name:WABASH VALLEY UROLOGICAL ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BHARAT
Authorized Official - Middle Name:G
Authorized Official - Last Name:DAVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-232-9596
Mailing Address - Street 1:1235 OHIO STREET
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807
Mailing Address - Country:US
Mailing Address - Phone:812-232-9596
Mailing Address - Fax:812-232-7992
Practice Address - Street 1:1235 OHIO STREET
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807
Practice Address - Country:US
Practice Address - Phone:812-232-9596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100250050AMedicaid
INCB5192Medicare PIN
IN100250050AMedicaid