Provider Demographics
NPI:1407203672
Name:CREDO HEALTH GROUP, LLC
Entity Type:Organization
Organization Name:CREDO HEALTH GROUP, LLC
Other - Org Name:CREDO FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:MULLALLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-445-5829
Mailing Address - Street 1:10228 DUPONT CIRCLE DR E # 100B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1611
Mailing Address - Country:US
Mailing Address - Phone:260-432-6459
Mailing Address - Fax:
Practice Address - Street 1:10228 DUPONT CIRCLE DR E # 100B
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1611
Practice Address - Country:US
Practice Address - Phone:260-432-6459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074259A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty