Healthcare Provider Details

I. General information

NPI: 1366859779
Provider Name (Legal Business Name): NORTHEAST INTERNAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N DETROIT ST
LAGRANGE IN
46761-1158
US

IV. Provider business mailing address

PO BOX 236
LAGRANGE IN
46761-0236
US

V. Phone/Fax

Practice location:
  • Phone: 260-463-2133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number71004993A
License Number StateIN

VIII. Authorized Official

Name: TARA GILMORE
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 260-463-2133