Provider Demographics
NPI:1013029883
Name:PRIMARY CARE PC
Entity Type:Organization
Organization Name:PRIMARY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:BLUMENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-762-3175
Mailing Address - Street 1:3125 WILLOWCREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368
Mailing Address - Country:US
Mailing Address - Phone:219-762-3175
Mailing Address - Fax:219-763-3092
Practice Address - Street 1:3125 WILLOWCREEK ROAD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368
Practice Address - Country:US
Practice Address - Phone:219-762-3175
Practice Address - Fax:219-763-3092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50004219A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200272620Medicaid
IN200272620Medicaid
IN4157960001Medicare NSC