Provider Demographics
NPI:1558309492
Name:MED SPA WOMANS HEALTHCARE
Entity Type:Organization
Organization Name:MED SPA WOMANS HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE ADMINISTRATOR CO-OFFICE
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-362-4690
Mailing Address - Street 1:PO BOX 9721
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46361
Mailing Address - Country:US
Mailing Address - Phone:219-362-4690
Mailing Address - Fax:219-362-4692
Practice Address - Street 1:220 DUNES PLAZA
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360
Practice Address - Country:US
Practice Address - Phone:219-879-6262
Practice Address - Fax:219-362-4692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052711A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN233370Medicare ID - Type Unspecified
H20934Medicare UPIN