Provider Demographics
NPI:1558462101
Name:CONCORD FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:CONCORD FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRATICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PLANERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-522-1201
Mailing Address - Street 1:25651 COUNTY ROAD 20
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46517-2310
Mailing Address - Country:US
Mailing Address - Phone:574-522-1201
Mailing Address - Fax:
Practice Address - Street 1:25651 COUNTY ROAD 20
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-2310
Practice Address - Country:US
Practice Address - Phone:574-522-1201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100113550AMedicaid
IN184350Medicare PIN