Healthcare Provider Details

I. General information

NPI: 1891311791
Provider Name (Legal Business Name): COMMUNITY MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 STATE ROAD 64 STE 101
GEORGETOWN IN
47122-9178
US

IV. Provider business mailing address

5300 STATE ROAD 64 STE 101
GEORGETOWN IN
47122-9178
US

V. Phone/Fax

Practice location:
  • Phone: 812-590-1600
  • Fax: 812-590-6561
Mailing address:
  • Phone: 812-590-1600
  • Fax: 812-590-6561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SYED BOKHARI
Title or Position: PRACTICE MANAGER
Credential:
Phone: 812-590-1600