Healthcare Provider Details

I. General information

NPI: 1487949889
Provider Name (Legal Business Name): MEDICAL ASSOCIATES OF NWI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3156 WILLOWCREEK RD
PORTAGE IN
46368-4424
US

IV. Provider business mailing address

2700 VALPARAISO ST # 2001
VALPARAISO IN
46383-3123
US

V. Phone/Fax

Practice location:
  • Phone: 219-762-4999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01065464A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number01065464A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number01065464A
License Number StateIN

VIII. Authorized Official

Name: DR. GAURAV KUMAR
Title or Position: OWNER
Credential: MD
Phone: 219-762-4999