Healthcare Provider Details

I. General information

NPI: 1568147809
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP INDIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N. ELKHART ST
WAKARUSA IN
46573
US

IV. Provider business mailing address

PO BOX 778985
CHICAGO IL
60677-8985
US

V. Phone/Fax

Practice location:
  • Phone: 574-296-3200
  • Fax:
Mailing address:
  • Phone: 574-296-3390
  • Fax: 574-296-3392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MEGAN LEIGH CARLSON
Title or Position: PROVIDER ENROLLMENT
Credential:
Phone: 574-296-3991