Basic Information
| Provider Information | |||||||||
| NPI: | 1467603746 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELKHART CLINIC, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EDISON LAKES UROLOGY - MICHIGAN OFFICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2968 | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465152968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5748555800 | ||||||||
| FaxNumber: | 5748555805 | ||||||||
| Practice Location | |||||||||
| Address1: | 804 E FRONT ST | ||||||||
| Address2: | |||||||||
| City: | BUCHANAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491071444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5748555800 | ||||||||
| FaxNumber: | 5748555805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2008 | ||||||||
| LastUpdateDate: | 10/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | BUSBY | ||||||||
| AuthorizedOfficialFirstName: | DARRYL | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5742963200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.