Provider Demographics
NPI:1720097322
Name:FOUNDATIONS FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:FOUNDATIONS FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:COOKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-794-8100
Mailing Address - Street 1:25 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:IN
Mailing Address - Zip Code:47102-1303
Mailing Address - Country:US
Mailing Address - Phone:812-794-8100
Mailing Address - Fax:812-794-8200
Practice Address - Street 1:25 W MAIN ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:IN
Practice Address - Zip Code:47102-1303
Practice Address - Country:US
Practice Address - Phone:812-794-8100
Practice Address - Fax:812-794-8200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056407A261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200490500AMedicaid
INDC0744OtherRR MEDICARE
IN218850Medicare PIN
IN153883Medicare Oscar/Certification