Healthcare Provider Details

I. General information

NPI: 1225095912
Provider Name (Legal Business Name): MICHAEL T. BRENDLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W EDISON RD SUITE 110
MISHAWAKA IN
46545-2784
US

IV. Provider business mailing address

620 W EDISON RD SUITE 110
MISHAWAKA IN
46545-2784
US

V. Phone/Fax

Practice location:
  • Phone: 574-258-1100
  • Fax: 574-258-1101
Mailing address:
  • Phone: 574-258-1100
  • Fax: 574-258-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01038512
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: