Provider Demographics
NPI:1144683301
Name:MOBILE PHYSICIANS GROUP LLC
Entity type:Organization
Organization Name:MOBILE PHYSICIANS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:219-464-9588
Mailing Address - Street 1:515 SILHAVY RD
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-4452
Mailing Address - Country:US
Mailing Address - Phone:219-464-9588
Mailing Address - Fax:219-462-4470
Practice Address - Street 1:2308 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2773
Practice Address - Country:US
Practice Address - Phone:219-464-9588
Practice Address - Fax:219-462-4470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001158A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1265759054OtherINDIVIDUAL NPI
IN07001158BOtherCSR
IN07001158AOtherLICENSE
IN201166760AMedicaid
P01563138OtherRR MEDICARE
P01563138OtherRR MEDICARE
P01563138OtherRR MEDICARE