Provider Demographics
NPI:1497946818
Name:WOLCOTT FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:WOLCOTT FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-279-2264
Mailing Address - Street 1:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:219-279-2264
Mailing Address - Fax:219-279-2279
Practice Address - Street 1:128 W MARKET STREET
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:IN
Practice Address - Zip Code:47995
Practice Address - Country:US
Practice Address - Phone:219-279-2264
Practice Address - Fax:219-279-2279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027166A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100196860Medicaid
INDB5648Medicare PIN
IN100196860Medicaid
IN218120Medicare PIN