Healthcare Provider Details

I. General information

NPI: 1497399927
Provider Name (Legal Business Name): PRIMARY CARE PARTNERS OF SOUTH BEND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S SAINT LOUIS BLVD STE 204
SOUTH BEND IN
46617-3044
US

IV. Provider business mailing address

300 S SAINT LOUIS BLVD STE 204
SOUTH BEND IN
46617-3044
US

V. Phone/Fax

Practice location:
  • Phone: 574-251-1200
  • Fax: 574-251-1230
Mailing address:
  • Phone: 574-251-1200
  • Fax: 574-251-1230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRANDON ZABUKOVIC
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 574-274-9425