Healthcare Provider Details

I. General information

NPI: 1174626014
Provider Name (Legal Business Name): INDIANA HEALTH CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W WESTERN AVE, STE B
SOUTH BEND IN
46619-3521
US

IV. Provider business mailing address

8003 CASTLEWAY DR
INDIANAPOLIS IN
46250-1946
US

V. Phone/Fax

Practice location:
  • Phone: 574-234-9033
  • Fax: 574-847-7200
Mailing address:
  • Phone: 317-576-1335
  • Fax: 317-576-1339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. TRACY NAGEL
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 317-576-1335