Provider Demographics
NPI:1467631945
Name:HUNTINGTON MEDICAL GROUP PC
Entity Type:Organization
Organization Name:HUNTINGTON MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-356-4005
Mailing Address - Street 1:1601 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46750-1404
Mailing Address - Country:US
Mailing Address - Phone:260-356-4005
Mailing Address - Fax:260-356-3501
Practice Address - Street 1:1601 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-1404
Practice Address - Country:US
Practice Address - Phone:260-356-4005
Practice Address - Fax:260-356-3501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035103A207R00000X
IN01053659A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200926830Medicaid
IN110016196OtherTRAVELERS MEDICARE
IN100138210AMedicaid
IN110247671OtherTRAVELERS MEDICARE
IN110016196OtherTRAVELERS MEDICARE
IN100138210AMedicaid