Provider Demographics
NPI:1740439496
Name:SERGIWA, ADAM (MD, MPH, MRCP,DCH)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:SERGIWA
Suffix:
Gender:M
Credentials:MD, MPH, MRCP,DCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:9856 W 400 N
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-2910
Practice Address - Country:US
Practice Address - Phone:219-878-0882
Practice Address - Fax:219-878-0884
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-17
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049378A208M00000X, 261QP2300X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200199090BMedicaid
IN000000305691OtherANTHEM BC/BS
IN200199090BMedicaid