NPIMap

Organization Active NPI

Privia Medical Group Indiana, LLC

  • Multi-Specialty Clinic/Center
  • Elkhart, IN
National Provider Identifier
1013912286
Registry record updated Apr 17, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X
Legal business name
PRIVIA MEDICAL GROUP INDIANA, LLC
Practice address
303 S Nappanee St
Elkhart, IN 46514-2066
Phone
(574) 296-3200
Fax
(574) 296-3392
NPI assigned
Jun 15, 2005
Last updated
Apr 17, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 17, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Thomas Vandergrift
Title
Chief Executive Administrator
Phone
(574) 296-3200

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Multi-Specialty Clinic/Center 261QM1300X IN Primary

Addresses

Primary practice location

303 S Nappanee St
Elkhart, IN 46514-2066

Mailing address

PO Box 778985
Chicago, IL 60677-8985
Phone (574) 296-3200

Other identifiers 2

IdentifierTypeStateIssuer
0359310001OtherINDMERC PTAN
100466600AMedicaidIN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN, MI3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20040110000052 IN Part B Supplier - Clinic/Group Practice 2365341674 Receives reassigned benefits from 46 practitioners
16 other NPIs on this enrollment
Practice locations: Elkhart, IN; Wakarusa, IN; Mishawaka, IN
O20090116000467 MI Part B Supplier - Clinic/Group Practice 2365341674 Receives reassigned benefits from 2 practitioners
Practice locations: Three Rivers, MI
O20100930009890 IN DME Supplier - Multi-Specialty - PhysicianDME Supplier - Physician - OptometristDME Supplier - Optician 2365341674 Practice locations: Elkhart, IN

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 8

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
15D0682018Privia Medical Group Indiana303 S Nappanee St, Elkhart, IN 46514AccreditationDec 22, 2027

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Privia Medical Group Indiana, LLC303 S Nappanee St, Elkhart, IN 46514-2066(574) 296-3200 Blood Glucose Monitors/Supplies (Non-Mail Order)|Canes and/or Crutches|Orthoses: Custom Fabricated|Orthoses: Prefabricated (Non-Custom Fabricated)|Orthoses: Off-The-Shelf|Diabetic Shoes and Inserts|Diabetic Shoes/Inserts - Custom Accepts assignmentParticipating since Jan 1, 1998

National Provider Directory

National Provider Directory

Locations

2222 W Lexington Ave
#A
Elkhart, IN 46514
Phone (574) 294-3030

410 Park Pl
#B
Mishawaka, IN 46545
Phone (574) 564-5863

2855 Miller Dr
Ste 121
Plymouth, IN 46563
Phone (574) 647-1600

Practitioners & affiliated clinicians

Practitioners 58

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 58

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1118793600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1744848000000",
    "number": "1013912286",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 778985",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606778985",
            "telephone_number": "574-296-3200",
            "fax_number": "574-296-3392"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "303 S NAPPANEE ST",
            "city": "ELKHART",
            "state": "IN",
            "postal_code": "465142066",
            "telephone_number": "574-296-3200",
            "fax_number": "574-296-3392"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIVIA MEDICAL GROUP INDIANA, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-06-15",
        "last_updated": "2025-04-17",
        "certification_date": "2025-04-17",
        "status": "A",
        "authorized_official_last_name": "VANDERGRIFT",
        "authorized_official_first_name": "THOMAS",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE ADMINISTRATOR",
        "authorized_official_telephone_number": "574-296-3200",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": "IN",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DMERC PTAN",
            "identifier": "0359310001",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100466600A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Elkhart, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 17, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.