MEDICARE: GRACE ELIZABETH PODUCH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	10005102A	IN

General Provider Information

NPI Number	:	1467329185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE ELIZABETH PODUCH PA-C

Provider Business Mailing Address
First Line	:	750 N WOODBRIDGE DR
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47408-2778
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	463 S PARK RIDGE RD STE 101
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47401-8589
Country	:	US
Telephone Number	:	812-235-8496
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2025
Last Update Date	:	12/03/2025

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