Healthcare Provider Details

I. General information

NPI: 1912924937
Provider Name (Legal Business Name): NORTHWEST BONE AND JOINT, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 E 86TH AVE
MERRILLVILLE IN
46410-6382
US

IV. Provider business mailing address

255 E 90TH DR SUITE W1
MERRILLVILLE IN
46410-8103
US

V. Phone/Fax

Practice location:
  • Phone: 219-769-1670
  • Fax: 219-738-6716
Mailing address:
  • Phone: 219-793-9029
  • Fax: 219-738-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: H CARL MOULTRIE II
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 219-793-9029