Provider Demographics
NPI:1558531095
Name:AMERICAN FAMILY MEDICAL CENTER,LLC
Entity Type:Organization
Organization Name:AMERICAN FAMILY MEDICAL CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:M
Authorized Official - Last Name:KRAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-923-9200
Mailing Address - Street 1:315 W 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRIFFITH
Mailing Address - State:IN
Mailing Address - Zip Code:46319-1003
Mailing Address - Country:US
Mailing Address - Phone:219-923-9200
Mailing Address - Fax:219-923-9203
Practice Address - Street 1:315 W 35TH AVE
Practice Address - Street 2:
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-1003
Practice Address - Country:US
Practice Address - Phone:219-923-9200
Practice Address - Fax:219-923-9203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029360207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100215510Medicaid
IND88670Medicare UPIN
IN709360Medicare PIN