Provider Demographics
NPI:1982758140
Name:SHARP MEDICAL PRACTICE
Entity Type:Organization
Organization Name:SHARP MEDICAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SHARP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-463-4896
Mailing Address - Street 1:2600 N DETROIT ST
Mailing Address - Street 2:PO BOX 168
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761
Mailing Address - Country:US
Mailing Address - Phone:260-463-4896
Mailing Address - Fax:260-463-5242
Practice Address - Street 1:2600 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761
Practice Address - Country:US
Practice Address - Phone:260-463-4896
Practice Address - Fax:260-463-5242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1047132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200102520Medicaid
ING30438Medicare UPIN
IN134810Medicare ID - Type Unspecified