Provider Demographics
NPI:1366464869
Name:MIDDLEBURY FAMILY PHYSICIANS, INC
Entity Type:Organization
Organization Name:MIDDLEBURY FAMILY PHYSICIANS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:WENDLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-825-2146
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-0459
Mailing Address - Country:US
Mailing Address - Phone:574-825-2146
Mailing Address - Fax:574-825-2182
Practice Address - Street 1:206 W. WARREN STREET
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540-0459
Practice Address - Country:US
Practice Address - Phone:574-825-2146
Practice Address - Fax:574-825-2182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCB2090OtherR/R MEDICARE
IN223490Medicare ID - Type UnspecifiedMILLERSBURG SITE
IN223520Medicare ID - Type UnspecifiedMIDDLEBURY SITE