Healthcare Provider Details

I. General information

NPI: 1720097322
Provider Name (Legal Business Name): FOUNDATIONS FAMILY MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W MAIN ST
AUSTIN IN
47102-1303
US

IV. Provider business mailing address

25 W MAIN ST
AUSTIN IN
47102-1303
US

V. Phone/Fax

Practice location:
  • Phone: 812-794-8100
  • Fax: 812-794-8200
Mailing address:
  • Phone: 812-794-8100
  • Fax: 812-794-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number01056407A
License Number StateIN

VIII. Authorized Official

Name: DR. WILLIAM E COOKE
Title or Position: DIRECTOR/OFFICER
Credential: MD
Phone: 812-794-8100