MEDICARE: MI PRIMARY CARE PRACTICE, 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	207K00000X	Allergy & Immunology Physician

General Provider Information

NPI Number	:	1811631641
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MI PRIMARY CARE PRACTICE, PC

Provider Business Mailing Address
First Line	:	PO BOX 500
Second Line	:
City	:	ELLICOTTVILLE
State	:	NY
Zip	:	14731-0500
Country	:	US
Telephone Number	:	716-699-9032
Fax Number	:	716-699-9035

Provider Business Practice Location Address
First Line	:	1313 W MCGALLIARD RD STE 2
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47303-1774
Country	:	US
Telephone Number	:	765-216-3115
Fax Number	:	765-216-3116

Authorized Official
Title or Position	:	MANAGER
Name	:	TRACY SCIOLINO
Credential	:
Telephone Number	:	716-699-9032

Provider Enumeration Date	:	04/27/2022
Last Update Date	:	11/23/2022

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