1285942599 NPI number — ORTHOPEDIC AND SPORTS MEDICINE CENTER OF NORTHERN INDIANA, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285942599 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:
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:
1285942599
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2021
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:
574-264-0179
Provider Business Mailing Address Fax Number:
574-262-9650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 NORTH MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLEBURY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46540-8608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-825-8685
Provider Business Practice Location Address Fax Number:
574-825-1256
Provider Enumeration Date:
09/21/2010

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:
574-264-0179

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




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