Provider Demographics
NPI:1093091928
Name:INDIANA PHYSICIAN MANAGEMENT-LOGANSPORT, LLC
Entity Type:Organization
Organization Name:INDIANA PHYSICIAN MANAGEMENT-LOGANSPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:
Authorized Official - Last Name:BICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-338-5053
Mailing Address - Street 1:7166 SOLUTION CTR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-0001
Mailing Address - Country:US
Mailing Address - Phone:317-870-6752
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:1101 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1528
Practice Address - Country:US
Practice Address - Phone:317-870-0480
Practice Address - Fax:317-870-0499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201040470AMedicaid
INM100061751Medicare PIN