Provider Demographics
NPI:1629623913
Name:MY MOBILE MD NORTHERN INDIANA
Entity Type:Organization
Organization Name:MY MOBILE MD NORTHERN INDIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PARTNER
Authorized Official - Phone:317-670-6635
Mailing Address - Street 1:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47390-0305
Mailing Address - Country:US
Mailing Address - Phone:765-969-7841
Mailing Address - Fax:
Practice Address - Street 1:429 E VERMONT ST STE 110
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3685
Practice Address - Country:US
Practice Address - Phone:317-559-0950
Practice Address - Fax:317-936-3028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-05
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty