Healthcare Provider Details

I. General information

NPI: 1326654070
Provider Name (Legal Business Name): PROVIDENCE MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 N CAPITOL AVE STE 107
INDIANAPOLIS IN
46202-6403
US

IV. Provider business mailing address

4000 W 106TH ST STE 125-207
CARMEL IN
46032-7720
US

V. Phone/Fax

Practice location:
  • Phone: 716-686-2104
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: OLUFUNKE LOUISE BRIMMO-LONGE
Title or Position: OWNER
Credential:
Phone: 716-686-2104