Provider Demographics
NPI:1619915170
Name:MIDWEST COMMUNITY HEALTH ASSOCIATES, INC.
Entity Type:Organization
Organization Name:MIDWEST COMMUNITY HEALTH ASSOCIATES, INC.
Other - Org Name:BRYAN MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-636-4517
Mailing Address - Street 1:3702 NEW VISION DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:260-266-6013
Mailing Address - Fax:260-458-5636
Practice Address - Street 1:442 W HIGH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1681
Practice Address - Country:US
Practice Address - Phone:419-636-4517
Practice Address - Fax:419-636-6438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1092419Medicaid
OH1092419Medicaid
OH9123076Medicare PIN
OH9308733Medicare PIN
OH9308736Medicare PIN
OH9123078Medicare PIN
OH9123077Medicare PIN
OH9123073Medicare PIN
OH9123074Medicare PIN
OH0410530001Medicare NSC
OH9123079Medicare PIN
OH9123075Medicare PIN
OH9379521Medicare PIN
OH9308737Medicare PIN
OH9308738Medicare PIN
OH9123072Medicare PIN