Basic Information
| Provider Information | |||||||||
| NPI: | 1720097322 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOUNDATIONS FAMILY MEDICINE PC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 25 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471021303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127948100 | ||||||||
| FaxNumber: | 8127948200 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471021303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127948100 | ||||||||
| FaxNumber: | 8127948200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COOKE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8127948100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 01056407A | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 200490500A | 05 | IN | MEDICAID | DC0744 | 01 | IN | RR MEDICARE | OTHER |