Healthcare Provider Details

I. General information

NPI: 1427048099
Provider Name (Legal Business Name): MARK M WALSH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E LASALLE EMERGENCY DEPARTMENT
SOUTH BEND IN
46617-2814
US

IV. Provider business mailing address

3371 CLEVELAND RD SUITE 210
SOUTH BEND IN
46628-9780
US

V. Phone/Fax

Practice location:
  • Phone: 574-237-7111
  • Fax: 574-273-1137
Mailing address:
  • Phone: 574-271-2558
  • Fax: 574-273-1137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01035916A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number01035916A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: