Provider Demographics
NPI:1447476528
Name:CLARKSVILLE PRIMARY CARE, LLC
Entity type:Organization
Organization Name:CLARKSVILLE PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:BADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-282-4283
Mailing Address - Street 1:140 E MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129-1852
Mailing Address - Country:US
Mailing Address - Phone:812-282-4283
Mailing Address - Fax:812-282-4293
Practice Address - Street 1:140 E MAPLE CT
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-1852
Practice Address - Country:US
Practice Address - Phone:812-282-4283
Practice Address - Fax:812-282-4293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1047589A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN218320Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER