Basic Information
| Provider Information | |||||||||
| NPI: | 1649254160 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERNAL MEDICINE CENTER OF NORTHWEST INDIANA PC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3535 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464091316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198844900 | ||||||||
| FaxNumber: | 2199807585 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464091316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198844900 | ||||||||
| FaxNumber: | 2199807585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 06/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | NWABARA | ||||||||
| AuthorizedOfficialFirstName: | OKECHI | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2198844900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | YES | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200030490 | 05 | IN | MEDICAID |