Basic Information
| Provider Information | |||||||||
| NPI: | 1376976571 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OURHEALTH PHYSICIAN GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OURCLINIC @ BRAUN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4151 E 96TH ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462401442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664343255 | ||||||||
| FaxNumber: | 8664220915 | ||||||||
| Practice Location | |||||||||
| Address1: | 144 S. COUNTY ROAD 100 W | ||||||||
| Address2: | |||||||||
| City: | WINAMAC | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743553111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2013 | ||||||||
| LastUpdateDate: | 10/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | WELLS | ||||||||
| AuthorizedOfficialFirstName: | JEFFERY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3175220823 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.