Basic Information
| Provider Information | |||||||||
| NPI: | 1013014158 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHPARTNERS MEDICAL GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTHPARTNERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35682 EAGLE WAY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606781356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198796531 | ||||||||
| FaxNumber: | 2198727869 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 E COOLSPRING AVE | ||||||||
| Address2: | |||||||||
| City: | MICHIGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463606312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198796531 | ||||||||
| FaxNumber: | 2198785015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | KELLER | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2198732905 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | DD6703 | 01 | RR MEDICARE | OTHER | 200489550 | 05 | IN | MEDICAID | 000000347031 | 01 | IN | ANTHEM | OTHER |