MEDICARE: INTERNAL MEDICINE CENTER OF NW INDIANA, PC

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	227800000X	Certified Respiratory Therapist	30001586A	IN
2	227800000X	Certified Respiratory Therapist	30001325A	IN
3	225100000X	Physical Therapist	05007981A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689712093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERNAL MEDICINE CENTER OF NW INDIANA, PC

Provider Business Mailing Address
First Line	:	5800 BROADWAY
Second Line	:
City	:	MERRILLVILLE
State	:	IN
Zip	:	46410-2601
Country	:	US
Telephone Number	:	219-985-1112
Fax Number	:	219-985-1150

Provider Business Practice Location Address
First Line	:	5800 BROADWAY
Second Line	:
City	:	MERRILLVILLE
State	:	IN
Zip	:	46410-2601
Country	:	US
Telephone Number	:	219-985-1112
Fax Number	:	219-985-1150

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. ROBYN DALE POLK
Credential	:	CRTT
Telephone Number	:	219-985-1112

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	04/12/2011

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