Organization
PRIVIA MEDICAL GROUP INDIANA, LLC
Active
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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