1396154324 NPI number — SAINT JOSEPH REGIONAL MEDICAL CENTER-SOUTH BEND CAMPUS, INC.

Table of content: (NPI 1396154324)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396154324 NPI number — SAINT JOSEPH REGIONAL MEDICAL CENTER-SOUTH BEND CAMPUS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAINT JOSEPH REGIONAL MEDICAL CENTER-SOUTH BEND CAMPUS, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PEDIATRIC SPECIALTY CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396154324
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
707 CEDAR ST STE 200
Provider Second Line Business Mailing Address:
SAINT JOSEPH PHYSICIAN NETWORK-CBO
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46617-2057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-335-8700
Provider Business Mailing Address Fax Number:
574-335-0760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
234 CHAPIN ST STE I (I)
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46601-2571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-335-8250
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SINK
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT OF FINANCE
Authorized Official Telephone Number:
574-335-5000

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000894414 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100382210D , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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