Healthcare Provider Details

I. General information

NPI: 1295991222
Provider Name (Legal Business Name): MAPLEWOOD FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 08/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3270 INTERTECH DR SUITE B
ANGOLA IN
46703-7325
US

IV. Provider business mailing address

PO BOX 626
FREMONT IN
46737-0626
US

V. Phone/Fax

Practice location:
  • Phone: 260-665-9100
  • Fax: 260-665-9112
Mailing address:
  • Phone: 260-665-9100
  • Fax: 260-665-9112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01058292A
License Number StateIN

VIII. Authorized Official

Name: DR. CHRISTOPHER JAMES BRETZ
Title or Position: PHYSICIAN - OWNER
Credential: M.D.
Phone: 260-665-9100