Provider Demographics
NPI:1528151602
Name:NORTHERN INDIANA MATERNAL AND CHILD HEALTH NETWORK, INC
Entity type:Organization
Organization Name:NORTHERN INDIANA MATERNAL AND CHILD HEALTH NETWORK, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KONRATH
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, RN
Authorized Official - Phone:574-282-3230
Mailing Address - Street 1:244 S OLIVE ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46619-2106
Mailing Address - Country:US
Mailing Address - Phone:574-282-3230
Mailing Address - Fax:574-282-3240
Practice Address - Street 1:244 S OLIVE ST
Practice Address - Street 2:SUITE E
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46619-2106
Practice Address - Country:US
Practice Address - Phone:574-282-3230
Practice Address - Fax:574-282-3240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN200817480A251K00000X
IN200817480B261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200817480BMedicaid
IN200817480AMedicaid