Provider Demographics
NPI:1598842254
Name:R.B. GONZALES MEDICAL AND BARIATRIC CENTER INC.
Entity type:Organization
Organization Name:R.B. GONZALES MEDICAL AND BARIATRIC CENTER INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:M.A.
Authorized Official - Prefix:
Authorized Official - First Name:BOBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-235-4000
Mailing Address - Street 1:1361 FORT HARRISON RD
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804
Mailing Address - Country:US
Mailing Address - Phone:812-235-4000
Mailing Address - Fax:812-235-4004
Practice Address - Street 1:1361 FORT HARRISON RD
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804
Practice Address - Country:US
Practice Address - Phone:812-235-4000
Practice Address - Fax:812-235-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052731A207R00000X
IN132700000X
IN01035596207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No132700000XDietary & Nutritional Service ProvidersDietary ManagerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100326570Medicaid
IN200041630AMedicaid
IN100326570Medicaid
IN200041630AMedicaid