Provider Demographics
NPI:1659577146
Name:FAMILY MEDICINE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:FAMILY MEDICINE ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:IZAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-884-4450
Mailing Address - Street 1:PO BOX 10606
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46411-0606
Mailing Address - Country:US
Mailing Address - Phone:219-884-4450
Mailing Address - Fax:219-884-4418
Practice Address - Street 1:5857 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2666
Practice Address - Country:US
Practice Address - Phone:219-884-4450
Practice Address - Fax:212-884-4418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042994207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200523670AMedicaid
IN200523670AMedicaid