=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477600401
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROWN FAMILY MEDICINE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2007
-----------------------------------------------------
Last Update Date | 01/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 S WEST ST
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307-3908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-662-7583
-----------------------------------------------------
Fax | 219-662-7378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 SOUTH WEST STREET
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307-4848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-662-7583
-----------------------------------------------------
Fax | 219-662-7378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KAMARTAJ SAIFULLAH QUADRI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 219-662-7583
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 01050515A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------