Healthcare Provider Details

I. General information

NPI: 1336211481
Provider Name (Legal Business Name): MIDWEST INTEGRATED HEALTH SYSTEMS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 W 15TH AVE
GARY IN
46404-1963
US

IV. Provider business mailing address

PO BOX 4446 3300 W 15TH AVE
GARY IN
46404-0446
US

V. Phone/Fax

Practice location:
  • Phone: 219-944-3522
  • Fax: 219-944-3595
Mailing address:
  • Phone: 219-944-3522
  • Fax: 219-944-3595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number01038724
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01038724
License Number StateIN

VIII. Authorized Official

Name: MS. PERRY L MITCHELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 219-944-3522