Provider Demographics
NPI:1154382729
Name:NORTHEAST REGIONAL FAMILY PRACTICE P.C.
Entity type:Organization
Organization Name:NORTHEAST REGIONAL FAMILY PRACTICE P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:PEPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-422-8770
Mailing Address - Street 1:10327 DAWSONS CREEK BLVD 9 D
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825
Mailing Address - Country:US
Mailing Address - Phone:260-424-8770
Mailing Address - Fax:260-469-8774
Practice Address - Street 1:10327 DAWSONS CREEK BLVD 9 D
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825
Practice Address - Country:US
Practice Address - Phone:260-424-8770
Practice Address - Fax:260-469-8774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100103630DMedicaid
IN100103630DMedicaid
B28518Medicare UPIN