Provider Demographics
NPI:1619921558
Name:KNOX WINAMAC COMMUNITY HEALTH CENTERS, INC
Entity type:Organization
Organization Name:KNOX WINAMAC COMMUNITY HEALTH CENTERS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:R
Authorized Official - Last Name:FRITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-772-2188
Mailing Address - Street 1:1520 S HEATON ST
Mailing Address - Street 2:
Mailing Address - City:KNOX
Mailing Address - State:IN
Mailing Address - Zip Code:46534-2393
Mailing Address - Country:US
Mailing Address - Phone:574-772-2188
Mailing Address - Fax:574-772-2190
Practice Address - Street 1:1520 S HEATON ST
Practice Address - Street 2:
Practice Address - City:KNOX
Practice Address - State:IN
Practice Address - Zip Code:46534-2393
Practice Address - Country:US
Practice Address - Phone:574-772-2188
Practice Address - Fax:574-772-2190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50000720A261QR1300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000083056OtherBLUE CROSS BLUE SHIELD
IN200020860AMedicaid
IN50000720AOtherCORPORATION LICENSE
IN200897290Medicaid
IN100225090Medicaid
IN351301967OtherTAX ID
IN01024309AOtherWALTER FRITZ, M.D. LICENS
IN351301967OtherTAX ID
IN01024309AOtherWALTER FRITZ, M.D. LICENS
C25601Medicare UPIN
IN50000720AOtherCORPORATION LICENSE
IN151866Medicare Oscar/Certification