Healthcare Provider Details

I. General information

NPI: 1366097016
Provider Name (Legal Business Name): MIDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 N MAIN ST STE 1C
MISHAWAKA IN
46545-3100
US

IV. Provider business mailing address

3838 N MAIN ST STE 1C
MISHAWAKA IN
46545-3100
US

V. Phone/Fax

Practice location:
  • Phone: 574-404-3980
  • Fax: 574-931-8601
Mailing address:
  • Phone: 574-404-3980
  • Fax: 574-931-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: LLOYD SCHULMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 574-286-6802