Provider Demographics
NPI:1386771012
Name:MULTICARE PHYSICIAN CENTER PC
Entity type:Organization
Organization Name:MULTICARE PHYSICIAN CENTER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MLYNARCIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-712-6130
Mailing Address - Street 1:7863 BROADWAY
Mailing Address - Street 2:STE 135
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410
Mailing Address - Country:US
Mailing Address - Phone:219-548-0837
Mailing Address - Fax:219-548-0857
Practice Address - Street 1:7863 BROADWAY
Practice Address - Street 2:STE 135
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410
Practice Address - Country:US
Practice Address - Phone:219-736-2047
Practice Address - Fax:219-736-2048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049411174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200195840BMedicaid
IN000000080178OtherBLUE CROSS BLUE SHIELD
ING25543Medicare UPIN