Healthcare Provider Details

I. General information

NPI: 1417983537
Provider Name (Legal Business Name): INTERNAL MEDICINE,GERIATRICS AND ONCOLOGY GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 HAMSTROM RD
PORTAGE IN
46368-3832
US

IV. Provider business mailing address

2640 HAMSTROM RD
PORTAGE IN
46368-3832
US

V. Phone/Fax

Practice location:
  • Phone: 219-762-9523
  • Fax: 219-763-3120
Mailing address:
  • Phone: 219-762-9523
  • Fax: 219-763-3120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01027933A
License Number StateIN

VIII. Authorized Official

Name: MRS. DIANA G NEUMANN
Title or Position: BILLING CLERK
Credential:
Phone: 219-464-4786