Provider Demographics
NPI:1033581962
Name:NORTHWEST INDIANA MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:NORTHWEST INDIANA MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:IBRAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ZABANEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-836-1152
Mailing Address - Street 1:1644 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3970
Mailing Address - Country:US
Mailing Address - Phone:219-836-1152
Mailing Address - Fax:219-513-9162
Practice Address - Street 1:1644 45TH AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3970
Practice Address - Country:US
Practice Address - Phone:219-836-1152
Practice Address - Fax:219-513-9162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-30
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207V00000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01056213OtherLICENSE