Provider Demographics
NPI:1588016752
Name:OKOLOCHA MEDICAL CORPORATION
Entity Type:Organization
Organization Name:OKOLOCHA MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:OKOLOCHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-949-7540
Mailing Address - Street 1:2054 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46404-3060
Mailing Address - Country:US
Mailing Address - Phone:219-949-7540
Mailing Address - Fax:219-949-7545
Practice Address - Street 1:2054 GRANT ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46404-3060
Practice Address - Country:US
Practice Address - Phone:219-949-7540
Practice Address - Fax:219-949-7545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004976363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201272350Medicaid