| Nwi Mdvip Llc | |
|
9150 E 109th Ave Ste 2b Crown Point IN 46307-7686 | |
| (219) 213-2947 | |
| (219) 310-8175 |
| Full Name | Nwi Mdvip Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 9150 E 109th Ave Ste 2b, Crown Point, Indiana |
| Authorized Official Name and Position | Brent A Jacobus (OWNER) |
| Authorized Official Contact | 2193060752 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Nwi Mdvip Llc 9150 E 109th Ave Ste 2b Crown Point IN 46307-7686 Ph: (219) 306-0752 | Nwi Mdvip Llc 9150 E 109th Ave Ste 2b Crown Point IN 46307-7686 Ph: (219) 213-2947 |
| NPI Number | 1538877972 |
|---|---|
| Provider Enumeration Date | 11/14/2022 |
| Last Update Date | 11/14/2022 |
| Medicare PECOS PAC ID | 0042683690 |
|---|---|
| Medicare Enrollment ID | O20230301000520 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1538877972 | NPI | - | NPPES |
| 200380090 | Medicaid | IN | |
| 100200720 | Medicaid | IN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| Provider Name | Brett A Brechner |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1629079108 PECOS PAC ID: 6002887049 Enrollment ID: I20040804000103 |
| Provider Name | Brent A Jacobus |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1902807589 PECOS PAC ID: 2163494162 Enrollment ID: I20040810001164 |
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