Provider Demographics
NPI:1275827784
Name:FMMG HARRISON FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:FMMG HARRISON FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:EICHENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-948-7632
Mailing Address - Street 1:313 FEDERAL DR NW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-3070
Mailing Address - Country:US
Mailing Address - Phone:812-738-4155
Mailing Address - Fax:812-738-6104
Practice Address - Street 1:313 FEDERAL DR NW
Practice Address - Street 2:SUITE 200
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-3070
Practice Address - Country:US
Practice Address - Phone:812-738-4155
Practice Address - Fax:812-738-6104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-01
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201040630Medicaid
IN201040630Medicaid