Provider Demographics
NPI:1164846945
Name:ELKHART CLINIC, LLC
Entity Type:Organization
Organization Name:ELKHART CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BUSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-296-3200
Mailing Address - Street 1:PO BOX 2968
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-2968
Mailing Address - Country:US
Mailing Address - Phone:574-296-3200
Mailing Address - Fax:574-296-3392
Practice Address - Street 1:1122 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-3819
Practice Address - Country:US
Practice Address - Phone:574-296-3291
Practice Address - Fax:574-296-3383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100466600Medicaid
IN227950Medicare PIN