NPIMap

Organization Active NPI

Privia Medical Group Indiana, LLC

  • Multi-Specialty Clinic/Center
  • Elkhart, IN
National Provider Identifier
1730638990
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
25651 County Road 20
Elkhart, IN 46517-2310
Phone
(574) 522-1201
NPI assigned
Sep 29, 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. Kevin R Boyer
Title
Ceo
Phone
(574) 296-3254

Specialties & licenses 1

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

Addresses

Primary practice location

25651 County Road 20
Elkhart, IN 46517-2310

Mailing address

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

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.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
15D2123132Privia Medical Group Indiana, LLC25651 County Road 20, Elkhart, IN 46517AccreditationOct 12, 2027

National Provider Directory

National Provider Directory
Tax ID family
Elkhart Clinic LLC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the 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": "1475107200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1747008000000",
    "number": "1730638990",
    "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": "25651 COUNTY ROAD 20",
            "city": "ELKHART",
            "state": "IN",
            "postal_code": "465172310",
            "telephone_number": "574-522-1201"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIVIA MEDICAL GROUP INDIANA, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-09-29",
        "last_updated": "2025-05-12",
        "certification_date": "2025-05-12",
        "status": "A",
        "authorized_official_last_name": "BOYER",
        "authorized_official_first_name": "KEVIN",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "574-296-3254",
        "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": []
}

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.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.