Provider Demographics
NPI:1467603746
Name:ELKHART CLINIC, LLC
Entity Type:Organization
Organization Name:ELKHART CLINIC, LLC
Other - Org Name:EDISON LAKES UROLOGY - MICHIGAN OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BUSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-296-3200
Mailing Address - Street 1:PO BOX 2968
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-2968
Mailing Address - Country:US
Mailing Address - Phone:574-855-5800
Mailing Address - Fax:574-855-5805
Practice Address - Street 1:804 E FRONT ST
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-1444
Practice Address - Country:US
Practice Address - Phone:574-855-5800
Practice Address - Fax:574-855-5805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty