Provider Demographics
NPI:1205149218
Name:MIDWEST PROVIDER GROUP.DME
Entity type:Organization
Organization Name:MIDWEST PROVIDER GROUP.DME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:O'NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-677-6572
Mailing Address - Street 1:1449 NORTH PENNSYLVANIA ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202
Mailing Address - Country:US
Mailing Address - Phone:317-677-6572
Mailing Address - Fax:
Practice Address - Street 1:1449 N PENNSYLVANIA ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2420
Practice Address - Country:US
Practice Address - Phone:317-677-6572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health