Provider Demographics
NPI:1033292735
Name:GOSHEN FAMILY PHYSICIANS
Entity Type:Organization
Organization Name:GOSHEN FAMILY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCCLANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-534-0050
Mailing Address - Street 1:1811 CHARLTON CT
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-6464
Mailing Address - Country:US
Mailing Address - Phone:574-534-8200
Mailing Address - Fax:574-534-0411
Practice Address - Street 1:1811 CHARLTON CT
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6464
Practice Address - Country:US
Practice Address - Phone:574-534-8200
Practice Address - Fax:574-534-0411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300085359Medicaid