1104499649 NPI number — BLUE ELK FAMILY CLINIC LLC

Table of content: (NPI 1104499649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104499649 NPI number — BLUE ELK FAMILY CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE ELK FAMILY CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104499649
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8410 S 575 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46160-8492
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-640-4945
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 E WILLOW ST STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-200-8265
Provider Business Practice Location Address Fax Number:
833-972-1963
Provider Enumeration Date:
07/22/2021

Additional Information

Authorized Official

Authorized Official Last Name:
SANCHEZ
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
812-200-8265

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300046197 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000001485581 . This is a "ANTHEM PROVIDER ID" identifier . This identifiers is of the category "OTHER".




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