Basic Information
| Provider Information | |||||||||
| NPI: | 1780628545 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANA MEDICAL ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7900 W JEFFERSON BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609697100 | ||||||||
| FaxNumber: | 2609697101 | ||||||||
| Practice Location | |||||||||
| Address1: | 7900 W JEFFERSON BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609697100 | ||||||||
| FaxNumber: | 2609697101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 01/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | TESKA | ||||||||
| AuthorizedOfficialFirstName: | LOWELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2609697100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2042720 | 05 | OH | MEDICAID | 200190390 | 05 | IN | MEDICAID | 200250290 | 05 | IN | MEDICAID |