Healthcare Provider Details

I. General information

NPI: 1841344165
Provider Name (Legal Business Name): NORTHWEST INDIANA MEDICAL CONSULTANTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5304 BROADWAY
MERRILLVILLE IN
46410-1555
US

IV. Provider business mailing address

5304 BROADWAY
MERRILLVILLE IN
46410-1555
US

V. Phone/Fax

Practice location:
  • Phone: 219-985-2510
  • Fax: 219-985-2532
Mailing address:
  • Phone: 219-985-2510
  • Fax: 219-985-2532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number01046988
License Number StateIN

VIII. Authorized Official

Name: JOSETTE CHERIE JACKSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 219-985-2510