Provider Demographics
NPI:1265454755
Name:ASSOCIATED FAMILY MEDICAL CONSULTANTS PC
Entity Type:Organization
Organization Name:ASSOCIATED FAMILY MEDICAL CONSULTANTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:W
Authorized Official - Last Name:COIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-486-6197
Mailing Address - Street 1:6400 ROTHMAN RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-1366
Mailing Address - Country:US
Mailing Address - Phone:260-485-1544
Mailing Address - Fax:260-485-0490
Practice Address - Street 1:6400 ROTHMAN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-1366
Practice Address - Country:US
Practice Address - Phone:260-485-1544
Practice Address - Fax:260-485-0490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100462980Medicaid
IN185760Medicare ID - Type Unspecified
=========Medicare UPIN