Privia Medical Group Indiana, LLC
Organization Active NPI Family Nurse Practitioner · Wakarusa, IN
NPI 1568147809 · NPPES record last updated May 12, 2025
Key facts
- NPI
- 1568147809
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Nurse Practitioner 363LF0000X
- Legal business name
- PRIVIA MEDICAL GROUP INDIANA, LLC
- Practice address
- 100 N. Elkhart St
Wakarusa, IN 46573 - Phone
- (574) 296-3200
- NPI assigned
- Jun 15, 2023
- Organization subpart
- Yes
- Parent organization (as reported)
- ELKHART CLINIC, LLC
Authorized official
- Name
- Megan Leigh Carlson
- Title
- Provider Enrollment
- Phone
- (574) 296-3991
Parent organization (reported in NPPES) 1
Other NPIs on the same Medicare enrollment 8
Corporate family (same tax ID) 4
Practitioners 56
-
Matthew Lee Abrell, DPM
-
Kimberlee Lynn Acton, FNP-C
-
Pavan Ahuja, M.D.
-
Jennifer N Besemer, RD, CDE
-
Sam Joseph Borrelli, M.D.
-
William P Buckley, M.D.
-
John Walter Bulger, M.D.
-
Jeffrey Hassel Eifler, D.P.M.
-
Minnie S. Enriquez, M.D.
-
Kenneth L. Gammon, M.D.
-
Dayna L Gerring, FNP-BC
-
Luisito C. Gonzales, M.D.
-
Nicole R Graves, NP
-
Ahsanul Haque, M.D.
-
Jennifer Ann Hartl, FNP-C
-
Melissa A Henderson, O.D
-
Nazmul Huda, MD
-
Carolyn F. Hudson, M.D.
-
Gordon M Hughes, MD
-
James Ou Jin, M.D.
-
Abigail Anne Johnson, M.A.
-
Eric M Johnson, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IN
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
- Tax ID family
- Elkhart Clinic
- Part of
- Elkhart Clinic
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Nurse Practitioner |
363LF0000X | Yes |
Addresses
Primary practice location
100 N. Elkhart St
Wakarusa, IN 46573
Mailing address
PO Box 778985
Chicago, IL 60677-8985
Phone (574) 296-3390
Other names
- Elkhart Clinic Wakarusa
Other providers in Wakarusa, IN
- Beth Ann Lockwood
- Miller'S Health Systems, Inc.
- Lisa Mills
- Mosaic Prosthetic Solutions LLC
- Menessah Mullett
- Seifert Healthcare LLC
- Seifert Healthcare LLC
- Brent Douglas Sonner III
- The Waters of Wakarusa Skilled Nursing Facility LLC
- Tri-County Ambulance Service, Inc.
All providers in Wakarusa, IN · Family Nurse Practitioner in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 12, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.