Healthcare Provider Details

I. General information

NPI: 1730194416
Provider Name (Legal Business Name): EDNA PAMATMAT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W WESTERN AVE STE B
SOUTH BEND IN
46619-3570
US

IV. Provider business mailing address

8003 CASTLEWAY DR
INDIANAPOLIS IN
46250-1946
US

V. Phone/Fax

Practice location:
  • Phone: 574-234-9033
  • Fax: 844-397-1310
Mailing address:
  • Phone: 317-576-1335
  • Fax: 844-397-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-072396
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: