Provider Demographics
NPI:1942546890
Name:PIC INDIANA PC
Entity Type:Organization
Organization Name:PIC INDIANA PC
Other - Org Name:PHYSICIANS URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-713-2600
Mailing Address - Street 1:800 W FULTON MARKET FL 12
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1302
Mailing Address - Country:US
Mailing Address - Phone:224-354-1297
Mailing Address - Fax:412-458-3953
Practice Address - Street 1:505 W CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1003
Practice Address - Country:US
Practice Address - Phone:815-713-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-21
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201186520Medicaid
ININ1262Medicare PIN