Provider Demographics
NPI:1558763987
Name:CHRISTIAN CLINIC PC
Entity Type:Organization
Organization Name:CHRISTIAN CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:G
Authorized Official - Last Name:WAKEFIELD
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:219-866-0485
Mailing Address - Street 1:716 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-3083
Mailing Address - Country:US
Mailing Address - Phone:219-866-0485
Mailing Address - Fax:219-866-0889
Practice Address - Street 1:716 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-3083
Practice Address - Country:US
Practice Address - Phone:219-866-0485
Practice Address - Fax:219-866-0837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060733A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20052387OAMedicaid
ING55729Medicare UPIN