Provider Demographics
NPI:1215181888
Name:GREG M. MIELKE, M.D., P.C.
Entity Type:Organization
Organization Name:GREG M. MIELKE, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:YODER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-523-0885
Mailing Address - Street 1:1209 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-2139
Mailing Address - Country:US
Mailing Address - Phone:574-523-0885
Mailing Address - Fax:574-523-0382
Practice Address - Street 1:1209 HARRISON ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-2139
Practice Address - Country:US
Practice Address - Phone:574-523-0885
Practice Address - Fax:574-523-0382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0134860A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100113720Medicaid
IN100113720Medicaid
IN227190Medicare PIN