Provider Demographics
NPI:1558409698
Name:HOMETOWN HEALTHCARE PC
Entity Type:Organization
Organization Name:HOMETOWN HEALTHCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:AINSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-724-8700
Mailing Address - Street 1:955 HIGH ST
Mailing Address - Street 2:STE 2
Mailing Address - City:DECATUR
Mailing Address - State:IN
Mailing Address - Zip Code:46733-2326
Mailing Address - Country:US
Mailing Address - Phone:260-724-8700
Mailing Address - Fax:260-728-3821
Practice Address - Street 1:955 HIGH ST
Practice Address - Street 2:STE 2
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-2326
Practice Address - Country:US
Practice Address - Phone:260-724-8700
Practice Address - Fax:260-728-3821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045263A207Q00000X
IN71001926A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000105448OtherANTHEM
IN20274870AMedicaid
IN9132OtherPHP
IN080154120OtherRAILROAD MEDICARE
IN148540Medicare ID - Type Unspecified
IN9132OtherPHP
INQ50937Medicare UPIN