Healthcare Provider Details

I. General information

NPI: 1649241084
Provider Name (Legal Business Name): SOUTH BEND MEDICAL FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 DOUGLAS RD
SOUTH BEND IN
46635-1779
US

IV. Provider business mailing address

PO BOX 11957
FORT WAYNE IN
46862-1957
US

V. Phone/Fax

Practice location:
  • Phone: 574-234-4176
  • Fax:
Mailing address:
  • Phone: 800-288-8325
  • Fax: 419-866-5453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: TERRY PIPP
Title or Position: CFO
Credential:
Phone: 574-234-7176