Provider Demographics
NPI:1326654070
Name:PROVIDENCE MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLUFUNKE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:BRIMMO-LONGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-686-2104
Mailing Address - Street 1:4000 W 106TH ST STE 125-207
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-7720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1935 N CAPITOL AVE STE 107
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-6403
Practice Address - Country:US
Practice Address - Phone:716-686-2104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-18
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty