Healthcare Provider Details

I. General information

NPI: 1124487301
Provider Name (Legal Business Name): ETHAN WREN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NAVARRE PL STE 4440
SOUTH BEND IN
46601-1171
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-5300
  • Fax: 574-647-5305
Mailing address:
  • Phone: 574-647-2129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number02006816A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: