Provider Demographics
NPI:1013014158
Name:HEALTHPARTNERS MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:HEALTHPARTNERS MEDICAL GROUP, LLC
Other - Org Name:HEALTHPARTNERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-873-2905
Mailing Address - Street 1:35682 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-1356
Mailing Address - Country:US
Mailing Address - Phone:219-879-6531
Mailing Address - Fax:219-872-7869
Practice Address - Street 1:1225 E COOLSPRING AVE
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-6312
Practice Address - Country:US
Practice Address - Phone:219-879-6531
Practice Address - Fax:219-878-5015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD6703OtherRR MEDICARE
IN200489550Medicaid
IN000000347031OtherANTHEM
IN5710110004Medicare NSC
IN000000347031OtherANTHEM
IN217230Medicare PIN