Healthcare Provider Details

I. General information

NPI: 1639384001
Provider Name (Legal Business Name): WARSAW MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2219 DUBOIS DR
WARSAW IN
46580-3212
US

IV. Provider business mailing address

2219 DUBOIS DR
WARSAW IN
46580-3212
US

V. Phone/Fax

Practice location:
  • Phone: 574-269-3420
  • Fax: 574-269-2234
Mailing address:
  • Phone: 574-269-3420
  • Fax: 574-269-2234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01036480
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01034706A
License Number StateIN

VIII. Authorized Official

Name: DR. KISHAN T KISHAN
Title or Position: PARTNER
Credential: MD
Phone: 574-269-3420