Provider Demographics
NPI:1669424768
Name:MARCOTTE MEDICAL GROUP, PC
Entity type:Organization
Organization Name:MARCOTTE MEDICAL GROUP, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARCOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-365-6333
Mailing Address - Street 1:15900 W 101ST AVE
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311
Mailing Address - Country:US
Mailing Address - Phone:219-365-6333
Mailing Address - Fax:219-365-8291
Practice Address - Street 1:15900 W 101ST AVE
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311
Practice Address - Country:US
Practice Address - Phone:219-365-6333
Practice Address - Fax:219-365-8291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000363441OtherANTHEM
IL9932077OtherBCBS
IN200424880AMedicaid
IN5913390001OtherDMERC
IN5913390001Medicare NSC
IN000000363441OtherANTHEM
IL9932077OtherBCBS
IN200424880AMedicaid
IN200760Medicare PIN