1417240284 NPI number — ORTHOPEDIC AND SPORTS MEDICINE CENTER OF NORTHERN INDIANA, INC.

Table of content: (NPI 1417240284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417240284 NPI number — ORTHOPEDIC AND SPORTS MEDICINE CENTER OF NORTHERN INDIANA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOPEDIC AND SPORTS MEDICINE CENTER OF NORTHERN INDIANA, 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:
OSMC GOSHEN
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:
1417240284
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2310 CALIFORNIA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKHART
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46514-1228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-264-0791
Provider Business Mailing Address Fax Number:
574-262-9650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1775 E KERCHER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOSHEN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46526-6308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-533-0300
Provider Business Practice Location Address Fax Number:
574-971-4350
Provider Enumeration Date:
05/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MCLAUGHLIN
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
574-264-4163

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100111780D , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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