| Privia Medical Group Indiana, Llc | |
|
303 S Nappanee St Elkhart IN 46514-2066 | |
| (574) 296-3200 | |
| (574) 296-3392 |
| Full Name | Privia Medical Group Indiana, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 303 S Nappanee St, Elkhart, Indiana |
| Authorized Official Name and Position | Thomas Vandergrift (CHIEF EXECUTIVE ADMINISTRATOR) |
| Authorized Official Contact | 5742963200 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Privia Medical Group Indiana, Llc Po Box 778985 Chicago IL 60677-8985 Ph: (574) 296-3200 | Privia Medical Group Indiana, Llc 303 S Nappanee St Elkhart IN 46514-2066 Ph: (574) 296-3200 |
| NPI Number | 1013912286 |
|---|---|
| Provider Enumeration Date | 06/15/2005 |
| Last Update Date | 04/17/2025 |
| Medicare PECOS PAC ID | 2365341674 |
|---|---|
| Medicare Enrollment ID | O20090116000467 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1013912286 | NPI | - | NPPES |
| 0359310001 | Other | IN | DMERC PTAN |
| 100466600A | Medicaid | IN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | (Indiana) | Primary |
| Provider Name | Emily A Mitchell |
|---|---|
| Provider Type | Practitioner - General Surgery |
| Provider Identifiers | NPI Number: 1043537020 PECOS PAC ID: 0941519185 Enrollment ID: I20190626000574 |
| Provider Name | Matthew Deere |
|---|---|
| Provider Type | Practitioner - General Surgery |
| Provider Identifiers | NPI Number: 1952797771 PECOS PAC ID: 5799107314 Enrollment ID: I20220627002334 |
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