Providence Medical Associates LLC

Primary specialty

Medical Specialty Clinic/CenterTaxonomy code 261QM2500X

Legal business name

PROVIDENCE MEDICAL ASSOCIATES LLC

Practice address

1935 N Capitol Ave Ste 107
Indianapolis, IN 46202-6403

Phone

(716) 686-2104

NPI assigned

Sep 18, 2020

Organization subpart

No

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

Authorized official

Name

Olufunke Louise Brimmo-LongeNPI 1568418176

Title

Owner

Phone

(716) 686-2104

Specialties & licenses 1

Addresses

Locations

Interoperability endpoints

• FHIR API: https://api.platform.athenahealth.com/20460/brand/1/csg/1/fhir/r4

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Olufunke Louise Brimmo-Longe, M.D.

  • Psychiatry Physician
  • Carmel, IN
  • NPI 1568418176
  NPD Authorized official
• Cheryl V Facey-Graham, NP

  • Psychiatric/Mental Health Nurse Practitioner
  • Indianapolis, IN
  • NPI 1730377623
  NPD

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

{
    "created_epoch": "1600387200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1603324800000",
    "number": "1326654070",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4000 W 106TH ST STE 125-207",
            "city": "CARMEL",
            "state": "IN",
            "postal_code": "460327720"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1935 N CAPITOL AVE STE 107",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462026403",
            "telephone_number": "716-686-2104"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE MEDICAL ASSOCIATES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-09-18",
        "last_updated": "2020-10-22",
        "certification_date": "2020-10-22",
        "status": "A",
        "authorized_official_last_name": "BRIMMO-LONGE",
        "authorized_official_first_name": "OLUFUNKE",
        "authorized_official_middle_name": "LOUISE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "716-686-2104"
    },
    "taxonomies": [
        {
            "code": "261QM2500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Medical Specialty",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Gretchen Sophia Prout
• John William Prout III, PHARMD
• Elizabeth J Proven, M.A., CCC-SLP
• Mary Anita Provence, LCSW
• Christian Provenza
• Providing Ease at Home Care Services, LLC
• Providing Ease Home Health, LLC
• Meredith Price Provost, MD
• Nancy K Pruett, D.D.S.
• Carl Pruitt

• Medical Specialty Clinic/Center in Indianapolis, IN
• Providers in Indianapolis, IN by specialty
• Medical Specialty Clinic/Center in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.