NPIMap

Organization Active NPI

Privia Medical Group Indiana, LLC

  • Family Nurse Practitioner
  • Wakarusa, IN
National Provider Identifier
1568147809
Registry record updated May 12, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 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
Last updated
May 12, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
ELKHART CLINIC, LLCAs reported in NPPES

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
Megan Leigh Carlson
Title
Provider Enrollment
Phone
(574) 296-3991

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X Primary

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 1

  • Elkhart Clinic Wakarusa 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
Tax ID family
Elkhart Clinic LLC5 organizations share this tax ID, including this one
Part of
Elkhart Clinic LLC

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 56

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 56

NPI Registry JSON

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

{
    "created_epoch": "1686787200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1747008000000",
    "number": "1568147809",
    "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": "574-296-3390",
            "fax_number": "574-296-3392"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 N. ELKHART ST",
            "city": "WAKARUSA",
            "state": "IN",
            "postal_code": "46573",
            "telephone_number": "574-296-3200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIVIA MEDICAL GROUP INDIANA, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ELKHART CLINIC, LLC",
        "enumeration_date": "2023-06-15",
        "last_updated": "2025-05-12",
        "certification_date": "2025-05-12",
        "status": "A",
        "authorized_official_last_name": "CARLSON",
        "authorized_official_first_name": "MEGAN",
        "authorized_official_middle_name": "LEIGH",
        "authorized_official_title_or_position": "PROVIDER ENROLLMENT",
        "authorized_official_telephone_number": "574-296-3991"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Elkhart Clinic Wakarusa",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Elkhart Clinic Wakarusa",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Wakarusa, 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.