# PROVIDENCE MEDICAL ASSOCIATES LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1326654070
- **Authorized official:** OLUFUNKE LOUISE BRIMMO-LONGE (OWNER)
- **Authorized official phone:** (716) 686-2104

## Contact information

- **Practice address:** 1935 N CAPITOL AVE STE 107, INDIANAPOLIS, IN 46202-6403
- **Practice address phone:** (716) 686-2104
- **Mailing address:** 4000 W 106TH ST STE 125-207, CARMEL, IN 46032-7720

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM2500X | Medical Specialty Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 09/18/2020
- **Last updated:** 10/22/2020