NPIMap

Organization Active NPI

Privia Medical Group Indiana, LLC

  • Multi-Specialty Clinic/Center
  • Elkhart, IN
National Provider Identifier
1083165708
Registry record updated May 12, 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
2222 W Lexington Ave
Suite B
Elkhart, IN 46514-1420
Phone
(574) 296-3200
Fax
(574) 296-3392
NPI assigned
Oct 18, 2016
Last updated
May 12, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 12, 2025

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

Authorized official

Name
Mr. Thomas Vandergrift
Title
Ceo
Phone
(574) 296-3200

Specialties & licenses 1

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

Addresses

Primary practice location

2222 W Lexington Ave
Suite B
Elkhart, IN 46514-1420

Mailing address

303 S Nappanee St
Elkhart, IN 46514-2066
Phone (574) 296-3200

Other names 1

  • Elkhart Clinic Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN2 enrollments

Enrollment records 2

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
This NPI is an additional NPI on the enrollment
Practice locations: Elkhart, IN; Wakarusa, IN; Mishawaka, IN
O20250319003886 IN DME Supplier - Physician - Neurology 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.

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 3

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.

NPI Registry JSON

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

{
    "created_epoch": "1476748800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1747008000000",
    "number": "1083165708",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2222 W LEXINGTON AVE",
            "address_2": "SUITE B",
            "city": "ELKHART",
            "state": "IN",
            "postal_code": "465141420",
            "telephone_number": "574-296-3200",
            "fax_number": "574-296-3392"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIVIA MEDICAL GROUP INDIANA, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-10-18",
        "last_updated": "2025-05-12",
        "certification_date": "2025-05-12",
        "status": "A",
        "authorized_official_last_name": "VANDERGRIFT",
        "authorized_official_first_name": "THOMAS",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "574-296-3200",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Elkhart Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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 May 12, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.