Healthcare Provider Details

I. General information

NPI: 1972776938
Provider Name (Legal Business Name): MISHAWAKA CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 04/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S. MAIN ST. SUITE 212
MISHAWAKA IN
46544
US

IV. Provider business mailing address

303 S. MAIN ST. SUITE 212
MISHAWAKA IN
46544
US

V. Phone/Fax

Practice location:
  • Phone: 574-254-0800
  • Fax: 574-254-0812
Mailing address:
  • Phone: 574-254-0800
  • Fax: 574-254-0812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES E. REIDY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 574-254-0800