Healthcare Provider Details

I. General information

NPI: 1992731905
Provider Name (Legal Business Name): MICHAEL JAMES PHEND M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 05/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 HOLY CROSS PARKWAY
MISHAWAKA IN
46545-1469
US

IV. Provider business mailing address

810 PARK PL
MISHAWAKA IN
46545-3520
US

V. Phone/Fax

Practice location:
  • Phone: 574-237-7168
  • Fax: 574-472-6262
Mailing address:
  • Phone: 574-472-6700
  • Fax: 574-472-6746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01030254A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01030254A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: