Basic Information
| Provider Information | |||||||||
| NPI: | 1013358365 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HOWARD PHYSICIAN NETWORK, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3500 S LAFOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469023803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176219312 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2013 | ||||||||
| LastUpdateDate: | 12/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | HOOPER | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3176217561 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | DU3904 | 01 | IN | GROUP MEDICARE RR | OTHER | 201183180 | 05 | IN | MEDICAID |