Provider Demographics
NPI:1033387824
Name:THE PROVIDER NETWORK, LLC
Entity Type:Organization
Organization Name:THE PROVIDER NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-507-4280
Mailing Address - Street 1:11688 LAKE FOREST PKWY
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-7208
Mailing Address - Country:US
Mailing Address - Phone:317-507-4280
Mailing Address - Fax:
Practice Address - Street 1:11688 LAKE FOREST PKWY
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46033-7208
Practice Address - Country:US
Practice Address - Phone:317-507-4280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2008876230AOtherIHCP FIRST STEPS