Healthcare Provider Details

I. General information

NPI: 1013191139
Provider Name (Legal Business Name): MAW MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 08/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 LAPORTE AVE SUITE 102
VALPARAISO IN
46383-5860
US

IV. Provider business mailing address

709 PLAZA DR STE 2 SUITE 164
CHESTERTON IN
46304-1573
US

V. Phone/Fax

Practice location:
  • Phone: 219-477-5242
  • Fax:
Mailing address:
  • Phone: 219-689-6637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number01048590A
License Number StateIN

VIII. Authorized Official

Name: MS. JACKIE WOODS
Title or Position: PHYSICIAN BILLER
Credential:
Phone: 219-689-6637