Provider Demographics
NPI:1558361592
Name:FAMILY LIFE CLINIC, PC
Entity Type:Organization
Organization Name:FAMILY LIFE CLINIC, PC
Other - Org Name:FAMILY LIFE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-947-0797
Mailing Address - Street 1:111 W 10TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-5990
Mailing Address - Country:US
Mailing Address - Phone:219-947-0797
Mailing Address - Fax:219-942-6243
Practice Address - Street 1:111 W 10TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-5990
Practice Address - Country:US
Practice Address - Phone:219-947-0797
Practice Address - Fax:219-942-6243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050865A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200251650Medicaid
H11148Medicare UPIN