Basic Information
| Provider Information | |||||||||
| NPI: | 1497946818 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOLCOTT FAMILY MEDICINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4699 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479034699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2192792264 | ||||||||
| FaxNumber: | 2192792279 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 W MARKET STREET | ||||||||
| Address2: | |||||||||
| City: | WOLCOTT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2192792264 | ||||||||
| FaxNumber: | 2192792279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 09/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | SHIELDS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2192792264 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01027166A | IN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100196860 | 05 | IN | MEDICAID |