Provider Demographics
NPI:1104499649
Name:BLUE ELK FAMILY CLINIC LLC
Entity type:Organization
Organization Name:BLUE ELK FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-200-8265
Mailing Address - Street 1:8410 S 575 W
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46160-8492
Mailing Address - Country:US
Mailing Address - Phone:414-640-4945
Mailing Address - Fax:
Practice Address - Street 1:50 E WILLOW ST STE C
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IN
Practice Address - Zip Code:47448
Practice Address - Country:US
Practice Address - Phone:812-200-8265
Practice Address - Fax:833-972-1963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300046197Medicaid
000001485581OtherANTHEM PROVIDER ID