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General NPI Number Information
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NPI Number | 1013380526
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Entity Type | Organization
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Legal Business Name | PRIVIA MEDICAL GROUP INDIANA, LLC
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Dates
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Enumeration Date | 11/05/2015
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Last Update Date | 05/12/2025
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Provider Practice Location Address
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Address Line | 2222 W LEXINGTON AVE
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City | ELKHART
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State | IN
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Zip | 46514-1420
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Country | US
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Telephone | 574-294-3030
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Fax | 574-296-3544
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Provider Business Mailing Address
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Address Line | PO BOX 2968
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City | ELKHART
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State | IN
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Zip | 46515-2968
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Country | US
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Telephone | 574-296-3200
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Fax | 574-296-3392
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Authorized Official
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Title or Position | CEO
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Name | THOMAS VANDERGRIFT
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Credential |
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Telephone | 574-296-3200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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