Provider Demographics
NPI:1235303165
Name:ELKHART CLINIC, LLC
Entity Type:Organization
Organization Name:ELKHART CLINIC, LLC
Other - Org Name:PRIMARY CARE AT MISHAWAKA
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PORSCHE
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 1:410 PARK PL
Practice Address - Street 2:SUITE B
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3557
Practice Address - Country:US
Practice Address - Phone:574-855-5800
Practice Address - Fax:574-855-5805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100466600DMedicaid
IN0359310002OtherMEDICARE NSC
IN100466600DMedicaid