Provider Demographics
NPI:1730713017
Name:NORTH CENTRAL INDIANA MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:NORTH CENTRAL INDIANA MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-832-6246
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:IN
Mailing Address - Zip Code:46542-0247
Mailing Address - Country:US
Mailing Address - Phone:574-832-6246
Mailing Address - Fax:574-832-2011
Practice Address - Street 1:112 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:IN
Practice Address - Zip Code:46542-3006
Practice Address - Country:US
Practice Address - Phone:574-832-6246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-26
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1902-89-0718OtherOB/GYN