Healthcare Provider Details

I. General information

NPI: 1427495878
Provider Name (Legal Business Name): INDIAN CREEK FAMILY HEALTH BROOKVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2013
Last Update Date: 10/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 MAIN ST
BROOKVILLE IN
47012-1280
US

IV. Provider business mailing address

617 MAIN ST
BROOKVILLE IN
47012-1280
US

V. Phone/Fax

Practice location:
  • Phone: 765-647-4231
  • Fax: 765-547-1414
Mailing address:
  • Phone: 765-647-4231
  • Fax: 765-547-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL FAIN
Title or Position: MEDICAL DIRECTOR/PHYSICIAN
Credential: D.O.
Phone: 765-647-4231