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General NPI Number Information
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NPI Number | 1013029883
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Entity Type | Organization
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Legal Business Name | PRIMARY CARE PC
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 08/07/2008
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Provider Practice Location Address
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Address Line | 3125 WILLOWCREEK ROAD
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City | PORTAGE
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State | IN
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Zip | 46368
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Country | US
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Telephone | 219-762-3175
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Fax | 219-763-3092
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Provider Business Mailing Address
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Address Line | 3125 WILLOWCREEK ROAD
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City | PORTAGE
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State | IN
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Zip | 46368
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Country | US
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Telephone | 219-762-3175
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Fax | 219-763-3092
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KENNETH WALTER BLUMENTHAL
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Credential | DO
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Telephone | 219-762-3175
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 50004219A
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License Number State | IN
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