1881177756 NPI number — MEMORIAL HOSPITAL OF SOUTH BEND

Table of content: KELLY MCCALL KNOTT PT (NPI 1922636091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881177756 NPI number — MEMORIAL HOSPITAL OF SOUTH BEND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEMORIAL HOSPITAL OF SOUTH BEND
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:
1881177756
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 N MICHIGAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46601-1033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-647-1000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3220 BEACON PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANGER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-999-8788
Provider Business Practice Location Address Fax Number:
574-999-8781
Provider Enumeration Date:
09/07/2018

Additional Information

Authorized Official

Authorized Official Last Name:
COSTELLO
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
PETER
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
574-647-3460

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300031565 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300032573 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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