Basic Information
| Provider Information | |||||||||
| NPI: | 1417996430 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST MEDICAL MANAGEMENT, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 42329 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191012329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007321066 | ||||||||
| FaxNumber: | 6309414333 | ||||||||
| Practice Location | |||||||||
| Address1: | 1606 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478042706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122387000 | ||||||||
| FaxNumber: | 8122387141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 03/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | STONE | ||||||||
| AuthorizedOfficialFirstName: | EDDIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8337321066 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000101352 | 01 | IN | BLUE SHIELD | OTHER | 100239300A | 05 | IN | MEDICAID |