Healthcare Provider Details

I. General information

NPI: 1811631641
Provider Name (Legal Business Name): MI PRIMARY CARE PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 W MCGALLIARD RD STE 2
MUNCIE IN
47303-1774
US

IV. Provider business mailing address

PO BOX 500
ELLICOTTVILLE NY
14731-0500
US

V. Phone/Fax

Practice location:
  • Phone: 765-216-3115
  • Fax: 765-216-3116
Mailing address:
  • Phone: 716-699-9032
  • Fax: 716-699-9035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACY SCIOLINO
Title or Position: MANAGER
Credential:
Phone: 716-699-9032