Healthcare Provider Details

I. General information

NPI: 1013110295
Provider Name (Legal Business Name): WABASH EM I MEDICAL SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MICHIGAN AVE
LOGANSPORT IN
46947-1528
US

IV. Provider business mailing address

533 W NORTH AVE STE. 102
ELMHURST IL
60126-2135
US

V. Phone/Fax

Practice location:
  • Phone: 574-753-7541
  • Fax: 574-753-1507
Mailing address:
  • Phone: 800-732-1066
  • Fax: 630-941-4333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateIN

VIII. Authorized Official

Name: KATHY KONDAS
Title or Position: OFFICER
Credential:
Phone: 954-838-2371