| Gsg Pride Healthcare Llc | |
|
8391 S Shady Trail Dr Pendleton IN 46064-8652 | |
| (317) 507-2395 | |
| Not Available |
| Full Name | Gsg Pride Healthcare Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 8391 S Shady Trail Dr, Pendleton, Indiana |
| Authorized Official Name and Position | Taris D Gonzalez (NURSE PRACTITIONER/OWNER) |
| Authorized Official Contact | 3177430009 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Gsg Pride Healthcare Llc 8391 S Shady Trail Dr Pendleton IN 46064-8652 Ph: (317) 743-0009 | Gsg Pride Healthcare Llc 8391 S Shady Trail Dr Pendleton IN 46064-8652 Ph: (317) 507-2395 |
| NPI Number | 1437622701 |
|---|---|
| Provider Enumeration Date | 01/09/2019 |
| Last Update Date | 01/30/2020 |
| Medicare PECOS PAC ID | 7113267022 |
|---|---|
| Medicare Enrollment ID | O20190312002841 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1437622701 | NPI | - | NPPES |
| 1821290743 | Medicaid | IN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QR1300X | Clinic/center - Rural Health | (* (Not Available)) | Secondary |
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Primary |
| Provider Name | Taris D Gonzalez |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1821290743 PECOS PAC ID: 1153595491 Enrollment ID: I20111122000526 |
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