Healthcare Provider Details

I. General information

NPI: 1336414499
Provider Name (Legal Business Name): MICHIANA NEUROLOGIC MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14404 STATE ROAD 23 STE B
GRANGER IN
46530-7778
US

IV. Provider business mailing address

1710 E DAY RD
MISHAWAKA IN
46545-4300
US

V. Phone/Fax

Practice location:
  • Phone: 574-252-7795
  • Fax: 574-252-7796
Mailing address:
  • Phone: 574-252-7795
  • Fax: 574-252-7796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number01037448A
License Number StateIN

VIII. Authorized Official

Name: KEVIN R KRISTL
Title or Position: M.D.
Credential:
Phone: 574-252-7795