Provider Demographics
NPI:1881046308
Name:FAMILY SPECIALTY MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:FAMILY SPECIALTY MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WAIL
Authorized Official - Middle Name:E
Authorized Official - Last Name:ASFOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-923-9200
Mailing Address - Street 1:3747 45TH ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-3008
Mailing Address - Country:US
Mailing Address - Phone:219-923-9200
Mailing Address - Fax:219-922-5904
Practice Address - Street 1:3747 45TH ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-3008
Practice Address - Country:US
Practice Address - Phone:219-923-9200
Practice Address - Fax:219-922-5904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-08
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053031A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01053031AMedicaid