1790743821 NPI number — NORTHERN BRACE COMPANY INC

Table of content: SEAN REINALD SUE M.D. (NPI 1861459968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790743821 NPI number — NORTHERN BRACE COMPANY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN BRACE COMPANY 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:
Provider Other Organization Name Type Code:
6
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:
1790743821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 N MICHIGAN ST
Provider Second Line Business Mailing Address:
STE. 104
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46601-1077
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-277-5548
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
53880 CARMICHAEL DR
Provider Second Line Business Practice Location Address:
STE. 220
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46635-1567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-277-5548
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEST
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
574-277-5548

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100153030B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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