Organization
INTERLOCAL COMMUNITY ACTION PROGRAM
Active
Other names
Mother Child Center
Organization subpart
No
Provider details
NPI number
Authorized official
MR. KEVIN POLIVICK (EXECUTIVE DIRECTOR)
(765) 529-4403
Entity
Organization
Contact information
Practice address
1912 BUNDY AVE, NEW CASTLE, IN 47362-2918
(765) 521-1401
Mailing address
1912 BUNDY AVE, NEW CASTLE, IN 47362-2918
Taxonomy
Speciality
Code
Description
License number
State
207VX0201X
Gynecologic Oncology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100134600
—
IN
Enumeration date
03/21/2007
Last updated
07/29/2008
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