Provider Demographics
NPI:1396780573
Name:DEMOTTE PHYSICIANS INC.
Entity type:Organization
Organization Name:DEMOTTE PHYSICIANS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDER LUGT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-987-3581
Mailing Address - Street 1:PO BOX 20
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-0020
Mailing Address - Country:US
Mailing Address - Phone:219-987-3581
Mailing Address - Fax:219-987-7137
Practice Address - Street 1:520 8TH AVE NE
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-9108
Practice Address - Country:US
Practice Address - Phone:219-987-3581
Practice Address - Fax:219-987-7137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000082478OtherBLUE CROSS/BLUE SHIELD
IN200489280AMedicaid
IN200489280AMedicaid