Healthcare Provider Details

I. General information

NPI: 1851497945
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP INDIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 PARK PL STE A
MISHAWAKA IN
46545-3557
US

IV. Provider business mailing address

410 PARK PL SUITE A
MISHAWAKA IN
46545-3557
US

V. Phone/Fax

Practice location:
  • Phone: 574-252-0667
  • Fax: 574-807-8845
Mailing address:
  • Phone: 574-252-0667
  • Fax: 574-807-8845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. KEVIN R BOYER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 574-296-3200