Healthcare Provider Details

I. General information

NPI: 1770613622
Provider Name (Legal Business Name): PRA MEDICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

IV. Provider business mailing address

PO BOX 182
MISHAWAKA IN
46546-0182
US

V. Phone/Fax

Practice location:
  • Phone: 574-299-2450
  • Fax: 574-273-6546
Mailing address:
  • Phone: 574-273-6546
  • Fax: 574-273-5295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number01027483A
License Number StateIN

VIII. Authorized Official

Name: YUPIDA PRASERTWANITCH
Title or Position: OWNER
Credential: MD
Phone: 574-273-6546