Healthcare Provider Details

I. General information

NPI: 1154371581
Provider Name (Legal Business Name): WILLIAM T. CORRELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 LAKE AVE STE 106
PLYMOUTH IN
46563-7830
US

IV. Provider business mailing address

707 CEDAR ST
SOUTH BEND IN
46617-2054
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-5220
  • Fax: 574-335-0859
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101014163DO
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101014163
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02007492A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: