MEDICARE: MIDDLEBURY URGENT CARE &OCCMED, P.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	208D00000X	General Practice Physician	02001282A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1396740585	OTHER	IN	NATIONAL PROVIDER IDENTIF

General Provider Information

NPI Number	:	1992766059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDDLEBURY URGENT CARE &OCCMED, P.C.

Provider Business Mailing Address
First Line	:	407 N MAIN ST
Second Line	:
City	:	MIDDLEBURY
State	:	IN
Zip	:	46540-9218
Country	:	US
Telephone Number	:	574-825-8184
Fax Number	:	574-825-6176

Provider Business Practice Location Address
First Line	:	407 N MAIN ST
Second Line	:
City	:	MIDDLEBURY
State	:	IN
Zip	:	46540-9218
Country	:	US
Telephone Number	:	574-825-8184
Fax Number	:	574-825-6176

Authorized Official
Title or Position	:	PRESIDENT/PHYSICIAN
Name	:	DR. STEVENS C MARSHALL
Credential	:	D.O.
Telephone Number	:	574-825-8184

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	08/22/2020

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