Provider Demographics
NPI:1841344165
Name:NORTHWEST INDIANA MEDICAL CONSULTANTS PC
Entity type:Organization
Organization Name:NORTHWEST INDIANA MEDICAL CONSULTANTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSETTE
Authorized Official - Middle Name:CHERIE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-985-2510
Mailing Address - Street 1:5304 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-1555
Mailing Address - Country:US
Mailing Address - Phone:219-985-2510
Mailing Address - Fax:219-985-2532
Practice Address - Street 1:5304 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-1555
Practice Address - Country:US
Practice Address - Phone:219-985-2510
Practice Address - Fax:219-985-2532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046988173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200148340BMedicaid