Healthcare Provider Details

I. General information

NPI: 1487307492
Provider Name (Legal Business Name): THE SOUTH BEND CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST
SOUTH BEND IN
46617-3096
US

IV. Provider business mailing address

211 N EDDY ST
SOUTH BEND IN
46617-3096
US

V. Phone/Fax

Practice location:
  • Phone: 574-239-1567
  • Fax:
Mailing address:
  • Phone: 574-239-1567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLY MACKEN-MARBLE
Title or Position: CEO
Credential:
Phone: 574-239-1567