Provider Demographics
NPI:1093927063
Name:J S MIDMORE MD PC
Entity Type:Organization
Organization Name:J S MIDMORE MD PC
Other - Org Name:JOHN STEVEN MIDMORE MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:MIDMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-988-0925
Mailing Address - Street 1:PO BOX 1873
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46384-1873
Mailing Address - Country:US
Mailing Address - Phone:219-476-0352
Mailing Address - Fax:219-531-0859
Practice Address - Street 1:3156 WILLOWCREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4424
Practice Address - Country:US
Practice Address - Phone:219-547-5999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0104887A2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100340370BMedicaid
INDU8259OtherRR MCR
ININ1919Medicare PIN