Provider Demographics
NPI:1649254160
Name:INTERNAL MEDICINE CENTER OF NORTHWEST INDIANA PC
Entity type:Organization
Organization Name:INTERNAL MEDICINE CENTER OF NORTHWEST INDIANA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OKECHI
Authorized Official - Middle Name:N
Authorized Official - Last Name:NWABARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-884-4900
Mailing Address - Street 1:3535 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46409-1316
Mailing Address - Country:US
Mailing Address - Phone:219-884-4900
Mailing Address - Fax:219-980-7585
Practice Address - Street 1:3535 BROADWAY
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-1316
Practice Address - Country:US
Practice Address - Phone:219-884-4900
Practice Address - Fax:219-980-7585
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-30
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200030490Medicaid
IN200030490Medicaid