MEDICARE: MIDWEST MEDICAL ASSOCIATES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01047204	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033215645
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST MEDICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	1116 MILLIS AVE
Second Line	:	SUITE 101
City	:	BOONVILLE
State	:	IN
Zip	:	47601-2242
Country	:	US
Telephone Number	:	812-897-7383
Fax Number	:	812-897-7236

Provider Business Practice Location Address
First Line	:	1116 MILLIS AVE
Second Line	:	SUITE 101
City	:	BOONVILLE
State	:	IN
Zip	:	47601-2242
Country	:	US
Telephone Number	:	812-897-7383
Fax Number	:	812-897-7236

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. MARIA RITA BOLISAY
Credential	:	MD
Telephone Number	:	812-897-7383

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	10/19/2007

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