Provider Demographics
NPI:1033215645
Name:MIDWEST MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MIDWEST MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLISAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-897-7383
Mailing Address - Street 1:1116 MILLIS AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47601-2242
Mailing Address - Country:US
Mailing Address - Phone:812-897-7383
Mailing Address - Fax:812-897-7236
Practice Address - Street 1:1116 MILLIS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-2242
Practice Address - Country:US
Practice Address - Phone:812-897-7383
Practice Address - Fax:812-897-7236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200404200AMedicaid
IN200404200AMedicaid