Healthcare Provider Details

I. General information

NPI: 1912951971
Provider Name (Legal Business Name): OBGYN ASSOCIATES OF NORTHERN IN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N MICHIGAN ST SUITE 200
SOUTH BEND IN
46601-1077
US

IV. Provider business mailing address

610 N MICHIGAN ST SUITE 200
SOUTH BEND IN
46601-1077
US

V. Phone/Fax

Practice location:
  • Phone: 574-232-1471
  • Fax: 574-239-8511
Mailing address:
  • Phone: 574-232-1471
  • Fax: 574-239-8511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. LEONARD FERGUSON
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 574-232-1471