Provider Demographics
NPI:1891375275
Name:MEDICINE REIMAGINED DPC
Entity Type:Organization
Organization Name:MEDICINE REIMAGINED DPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:STUCKEY-SCHROCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-319-1420
Mailing Address - Street 1:511 N GREENE RD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-1309
Mailing Address - Country:US
Mailing Address - Phone:574-319-1420
Mailing Address - Fax:
Practice Address - Street 1:1720 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5906
Practice Address - Country:US
Practice Address - Phone:574-319-1420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-10
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty