Organization
PRIVIA MEDICAL GROUP INDIANA, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. THOMAS VANDERGRIFT (CHIEF EXECUTIVE ADMINISTRATOR)
(574) 296-3200
Entity
Organization
Contact information
Practice address
303 S NAPPANEE ST, ELKHART, IN 46514-2066
(574) 296-3200
(574) 296-3392
Mailing address
PO BOX 778985, CHICAGO, IL 60677-8985
(574) 296-3200
(574) 296-3392
Taxonomy
Speciality
Code
Description
License number
State
261QM1300X
Multi-Specialty Clinic/Center
Primary
—
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0359310001
DMERC PTAN
IN
05
—
100466600A
—
IN
Enumeration date
06/15/2005
Last updated
04/17/2025
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