Healthcare Provider Details

I. General information

NPI: 1619915170
Provider Name (Legal Business Name): MIDWEST COMMUNITY HEALTH ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

442 W HIGH ST
BRYAN OH
43506-1681
US

IV. Provider business mailing address

3702 NEW VISION DR BLDG B
FORT WAYNE IN
46845-1703
US

V. Phone/Fax

Practice location:
  • Phone: 419-636-4517
  • Fax: 419-636-6438
Mailing address:
  • Phone: 260-266-6013
  • Fax: 260-458-5636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. DIANE CONRAD
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 419-636-4517