Provider Demographics
NPI:1275371080
Name:PROACTIVE MSO, LLC
Entity type:Organization
Organization Name:PROACTIVE MSO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL OPS PROJECT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:B
Authorized Official - Last Name:ADDAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-556-0017
Mailing Address - Street 1:124 ALLAWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-6207
Mailing Address - Country:US
Mailing Address - Phone:864-501-0751
Mailing Address - Fax:864-990-3834
Practice Address - Street 1:119 W 7TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3926
Practice Address - Country:US
Practice Address - Phone:864-501-0751
Practice Address - Fax:864-990-3834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-16
Last Update Date:2024-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care