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Organization

PROVIDENCE MEDICAL ASSOCIATES LLC

Active
Organization subpart
No

Provider details

NPI number
Authorized official
OLUFUNKE LOUISE BRIMMO-LONGE (OWNER)
(716) 686-2104
Entity
Organization

Contact information

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

Taxonomy

Speciality
Code
Description
License number
State
261QM2500X
Medical Specialty Clinic/Center
Primary

Other

Enumeration date
09/18/2020
Last updated
10/22/2020
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