Organization
SPECIAL MEDICINE CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. BINA GUPTA (OFFICE MANAGER)
(219) 874-8711
Entity
Organization
Contact information
Practice address
1501 WABASH ST STE 303, MICHIGAN CITY, IN 46360-4355
(219) 874-8711
(219) 874-9075
Mailing address
1501 WABASH ST STE 303, MICHIGAN CITY, IN 46360-4355
(219) 874-8711
(219) 874-9075
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
01029292A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000111817
BLUE CROSS BLUE SHIELD
KY
Enumeration date
01/30/2009
Last updated
01/30/2009
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