Provider Demographics
NPI:1942355466
Name:FAMILY MEDICINE CENTER OF PLYMOUTH PC
Entity Type:Organization
Organization Name:FAMILY MEDICINE CENTER OF PLYMOUTH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:A
Authorized Official - Last Name:BARNARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:574-936-3178
Mailing Address - Street 1:1904 LAKE AVE
Mailing Address - Street 2:P O BOX 969
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-7828
Mailing Address - Country:US
Mailing Address - Phone:574-936-3178
Mailing Address - Fax:574-936-1084
Practice Address - Street 1:1904 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7828
Practice Address - Country:US
Practice Address - Phone:574-936-3178
Practice Address - Fax:574-936-1084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001552261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000093835OtherANTHEM BCBS
IN20029880Medicaid
IN149770Medicare PIN
INF86733Medicare UPIN
IN20029880Medicaid