Provider Demographics
NPI:1235399726
Name:NORTHWEST CENTER MEDICAL SERVICES CORP
Entity Type:Organization
Organization Name:NORTHWEST CENTER MEDICAL SERVICES CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY, BOARD OF DIRECTORS
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:ILGENFRITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-980-6699
Mailing Address - Street 1:3400 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-1101
Mailing Address - Country:US
Mailing Address - Phone:219-980-6699
Mailing Address - Fax:219-980-6693
Practice Address - Street 1:3400 BROADWAY
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-1101
Practice Address - Country:US
Practice Address - Phone:219-980-6699
Practice Address - Fax:219-980-6693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034266A207SC0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SC0300XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical CytogeneticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100471020AMedicaid
IN982900Medicare PIN
IN100471020AMedicaid