Healthcare Provider Details

I. General information

NPI: 1669424768
Provider Name (Legal Business Name): MARCOTTE MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15900 W 101ST AVE
DYER IN
46311
US

IV. Provider business mailing address

15900 W 101ST AVE
DYER IN
46311
US

V. Phone/Fax

Practice location:
  • Phone: 219-365-6333
  • Fax: 219-365-8291
Mailing address:
  • Phone: 219-365-6333
  • Fax: 219-365-8291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. TREVOR M MARCOTTE
Title or Position: OWNER
Credential: DO
Phone: 219-365-6333