Provider Demographics
NPI:1194354530
Name:MYCARE EXPRESS CLINIC LLC
Entity type:Organization
Organization Name:MYCARE EXPRESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ATIMANAPARAMPIL
Authorized Official - Middle Name:N
Authorized Official - Last Name:DAMODARAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-806-4938
Mailing Address - Street 1:3608 W 80TH LN
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5061
Mailing Address - Country:US
Mailing Address - Phone:219-648-2786
Mailing Address - Fax:219-648-2782
Practice Address - Street 1:3608 W 80TH LN
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5061
Practice Address - Country:US
Practice Address - Phone:219-648-2786
Practice Address - Fax:183-391-4153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-07
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN8941233128Medicaid