Provider Demographics
NPI:1942488754
Name:NORTHWEST CENTER MEDICAL SERVICES CORP.
Entity Type:Organization
Organization Name:NORTHWEST CENTER MEDICAL SERVICES CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, GENETICS CENTER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZUNICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-980-6560
Mailing Address - Street 1:3400 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-1101
Mailing Address - Country:US
Mailing Address - Phone:219-980-6560
Mailing Address - Fax:219-980-6693
Practice Address - Street 1:3400 BROADWAY
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-1101
Practice Address - Country:US
Practice Address - Phone:219-980-6560
Practice Address - Fax:219-980-6693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034255A207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000079455OtherBLUE CROSS BLUE SHIELD PIN#
IN370019259OtherMEDICARE RAILROAD PIN
911-15448OtherBLUE CROSS BLUES SHIELD OF IL PROVIDER#
IN100213240AMedicaid
2047365OtherAETNA PROVIDER NUMBER
B29311Medicare UPIN
IN705110Medicare PIN