Provider Demographics
NPI:1538877972
Name:NWI MDVIP LLC
Entity type:Organization
Organization Name:NWI MDVIP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACOBUS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-306-0752
Mailing Address - Street 1:9150 E 109TH AVE STE 2B
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7686
Mailing Address - Country:US
Mailing Address - Phone:219-306-0752
Mailing Address - Fax:
Practice Address - Street 1:9150 E 109TH AVE STE 2B
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7686
Practice Address - Country:US
Practice Address - Phone:219-213-2947
Practice Address - Fax:219-310-8175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200380090Medicaid
IN100200720Medicaid