Healthcare Provider Details

I. General information

NPI: 1558568667
Provider Name (Legal Business Name): NORTHERN INDIANA REHABILITATION MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 07/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 E BARTLETT ST
SOUTH BEND IN
46601-1016
US

IV. Provider business mailing address

206 E BARTLETT ST
SOUTH BEND IN
46601-1016
US

V. Phone/Fax

Practice location:
  • Phone: 574-232-2222
  • Fax: 574-232-2224
Mailing address:
  • Phone: 574-232-2222
  • Fax: 574-232-2224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number01036492
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number01036492
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number01036492
License Number StateIN

VIII. Authorized Official

Name: DR. PETER L. YU
Title or Position: PRESIDENT AND MEDICAL DIRECTOR
Credential: M.D.
Phone: 574-232-2222