Provider Demographics
NPI:1972650950
Name:MERRILLVILLE CLINIC PC
Entity Type:Organization
Organization Name:MERRILLVILLE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RAMSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-331-9615
Mailing Address - Street 1:7899 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5284
Mailing Address - Country:US
Mailing Address - Phone:219-769-4333
Mailing Address - Fax:
Practice Address - Street 1:7899 TAFT ST
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5284
Practice Address - Country:US
Practice Address - Phone:219-769-4333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027935207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100468160AMedicaid
IN100468160AMedicaid