1194354530 NPI number — MYCARE EXPRESS CLINIC LLC

Table of content: (NPI 1194354530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194354530 NPI number — MYCARE EXPRESS CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYCARE EXPRESS 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:
1194354530
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3608 W 80TH LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERRILLVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46410-5061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-648-2786
Provider Business Mailing Address Fax Number:
219-648-2782

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3608 W 80TH LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERRILLVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46410-5061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-648-2786
Provider Business Practice Location Address Fax Number:
183-391-4153
Provider Enumeration Date:
04/07/2020

Additional Information

Authorized Official

Authorized Official Last Name:
DAMODARAN
Authorized Official First Name:
ATIMANAPARAMPIL
Authorized Official Middle Name:
N.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
574-806-4938

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8941233128 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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