Provider Demographics
NPI:1710459458
Name:360 INTEGRATED MEDICAL CENTER, PC
Entity Type:Organization
Organization Name:360 INTEGRATED MEDICAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-326-5100
Mailing Address - Street 1:2504 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-5241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2504 MONROE ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5241
Practice Address - Country:US
Practice Address - Phone:219-326-5100
Practice Address - Fax:219-326-0180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty