Provider Demographics
NPI:1952514895
Name:SACRIS MEDICAL CORPORATION PC
Entity Type:Organization
Organization Name:SACRIS MEDICAL CORPORATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:DELA VINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-462-4042
Mailing Address - Street 1:PO BOX 1338
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46384-1338
Mailing Address - Country:US
Mailing Address - Phone:219-462-4042
Mailing Address - Fax:219-462-1444
Practice Address - Street 1:2000 ROOSEVELT RD
Practice Address - Street 2:SUITE 207
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2800
Practice Address - Country:US
Practice Address - Phone:219-462-4042
Practice Address - Fax:219-462-1444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025728207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000109115OtherBLUE CROSS OF INDIANA
IN90000239OtherBLUE CROSS OF ILLINOIS
IN100076930AMedicaid
IN000000109115OtherBLUE CROSS OF INDIANA
IN90000239OtherBLUE CROSS OF ILLINOIS