Provider Demographics
NPI:1639405509
Name:MEDICAL SURGICAL WELLNESS CENTER, L.L.C
Entity Type:Organization
Organization Name:MEDICAL SURGICAL WELLNESS CENTER, L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:STREETER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-791-9782
Mailing Address - Street 1:300 W 80TH PL
Mailing Address - Street 2:SUITE A
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5456
Mailing Address - Country:US
Mailing Address - Phone:219-791-9782
Mailing Address - Fax:219-791-9787
Practice Address - Street 1:300 W 80TH PL
Practice Address - Street 2:SUITE A
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5456
Practice Address - Country:US
Practice Address - Phone:219-791-9782
Practice Address - Fax:219-791-9787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN020000320B208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000084728OtherANTHEM
IL9000235OtherILLINOIS BLUE CROSS/BLUE SHIELD
IL9000235OtherILLINOIS BLUE CROSS/BLUE SHIELD