Healthcare Provider Details

I. General information

NPI: 1033215645
Provider Name (Legal Business Name): MIDWEST MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 MILLIS AVE SUITE 101
BOONVILLE IN
47601-2242
US

IV. Provider business mailing address

1116 MILLIS AVE SUITE 101
BOONVILLE IN
47601-2242
US

V. Phone/Fax

Practice location:
  • Phone: 812-897-7383
  • Fax: 812-897-7236
Mailing address:
  • Phone: 812-897-7383
  • Fax: 812-897-7236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01047204
License Number StateIN

VIII. Authorized Official

Name: DR. MARIA RITA BOLISAY
Title or Position: PARTNER
Credential: MD
Phone: 812-897-7383