Healthcare Provider Details

I. General information

NPI: 1891787321
Provider Name (Legal Business Name): UNITED SURGEONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 EDISON LAKES PKWY
MISHAWAKA IN
46545-1442
US

IV. Provider business mailing address

4455 EDISON LAKES PKWY
MISHAWAKA IN
46545-1442
US

V. Phone/Fax

Practice location:
  • Phone: 574-968-0867
  • Fax: 574-968-0905
Mailing address:
  • Phone: 574-968-0867
  • Fax: 574-968-0905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateIN

VIII. Authorized Official

Name: DR. RICHARD BOLING II
Title or Position: CHAIRMAN OF THE BOARD
Credential: MD
Phone: 574-293-3545