Provider Demographics
NPI:1992766059
Name:MIDDLEBURY URGENT CARE &OCCMED, P.C.
Entity type:Organization
Organization Name:MIDDLEBURY URGENT CARE &OCCMED, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVENS
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:574-825-8184
Mailing Address - Street 1:407 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-9218
Mailing Address - Country:US
Mailing Address - Phone:574-825-8184
Mailing Address - Fax:574-825-6176
Practice Address - Street 1:407 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540-9218
Practice Address - Country:US
Practice Address - Phone:574-825-8184
Practice Address - Fax:574-825-6176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001282A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1396740585OtherNATIONAL PROVIDER IDENTIF
IN200840Medicare ID - Type Unspecified
IN1396740585OtherNATIONAL PROVIDER IDENTIF