Provider Demographics
NPI:1811992092
Name:ELKHART CLINIC ASC, LLC
Entity type:Organization
Organization Name:ELKHART CLINIC ASC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-296-3200
Mailing Address - Street 1:PO BOX 2997
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-2997
Mailing Address - Country:US
Mailing Address - Phone:574-296-3437
Mailing Address - Fax:574-296-3447
Practice Address - Street 1:2117 W LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1423
Practice Address - Country:US
Practice Address - Phone:574-296-3437
Practice Address - Fax:574-296-3447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN04-003903-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200263270AMedicaid
INZD5070Medicare PIN