NPIMap

Organization Active NPI

Privia Medical Group Indiana, LLC

  • Multi-Specialty Clinic/Center
  • Mishawaka, IN
National Provider Identifier
1235303165
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
410 Park PL
Suite B
Mishawaka, IN 46545-3557
Phone
(574) 855-5800
Fax
(574) 855-5805
NPI assigned
Apr 22, 2008
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
Dr. Timothy Porsche
Title
Managing Partner
Phone
(574) 296-3200

Specialties & licenses 1

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

Addresses

Primary practice location

410 Park PL
Suite B
Mishawaka, IN 46545-3557

Mailing address

PO Box 2968
Elkhart, IN 46515-2968
Phone (574) 296-3200

Other identifiers 2

IdentifierTypeStateIssuer
0359310002OtherINMEDICARE NSC
100466600DMedicaidIN

Other names 2

  • Edison Lakes Urology Other name
  • Primary Care at Mishawaka Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN

Enrollment records 1

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

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 5

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": "1208822400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1747008000000",
    "number": "1235303165",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2968",
            "city": "ELKHART",
            "state": "IN",
            "postal_code": "465152968",
            "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": "410 PARK PL",
            "address_2": "SUITE B",
            "city": "MISHAWAKA",
            "state": "IN",
            "postal_code": "465453557",
            "telephone_number": "574-855-5800",
            "fax_number": "574-855-5805"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIVIA MEDICAL GROUP INDIANA, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-22",
        "last_updated": "2025-05-12",
        "certification_date": "2025-05-12",
        "status": "A",
        "authorized_official_last_name": "PORSCHE",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_title_or_position": "MANAGING PARTNER",
        "authorized_official_telephone_number": "574-296-3200",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE NSC",
            "identifier": "0359310002",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100466600D",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Edison Lakes Urology",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Primary Care at Mishawaka",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Mishawaka, 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.