# NWI MDVIP LLC

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

## Provider details

- **NPI number:** 1538877972
- **Authorized official:** BRENT A JACOBUS DO (OWNER)
- **Authorized official phone:** (219) 306-0752

## Contact information

- **Practice address:** 9150 E 109TH AVE STE 2B, CROWN POINT, IN 46307-7686
- **Practice address phone:** (219) 213-2947
- **Practice address fax:** (219) 310-8175
- **Mailing address:** 9150 E 109TH AVE STE 2B, CROWN POINT, IN 46307-7686
- **Mailing address phone:** (219) 306-0752

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 11/14/2022
- **Last updated:** 11/14/2022