Provider Demographics
NPI:1982749867
Name:FAMILY PRACTICE OF JAY COUNTY
Entity type:Organization
Organization Name:FAMILY PRACTICE OF JAY COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HAGGENJOS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:260-726-8822
Mailing Address - Street 1:PO BOX 710
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-0710
Mailing Address - Country:US
Mailing Address - Phone:260-726-8822
Mailing Address - Fax:260-726-7857
Practice Address - Street 1:428 WEST VOTAW STREET, STE. A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-0710
Practice Address - Country:US
Practice Address - Phone:260-726-8822
Practice Address - Fax:260-726-7857
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JAY COUNTY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200923150Medicaid
IN200326550Medicaid
IN179970Medicare ID - Type Unspecified
IN200923150Medicaid