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General NPI Number Information
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NPI Number | 1013912286
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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 | 06/15/2005
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Last Update Date | 04/17/2025
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Provider Practice Location Address
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Address Line | 303 S NAPPANEE ST
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City | ELKHART
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State | IN
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Zip | 46514-2066
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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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Provider Business Mailing Address
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Address Line | PO BOX 778985
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City | CHICAGO
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State | IL
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Zip | 60677-8985
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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 | CHIEF EXECUTIVE ADMINISTRATOR
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Name | MR. 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 | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State | IN
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