Healthcare Provider Details

I. General information

NPI: 1821094525
Provider Name (Legal Business Name): MICHIANA GASTROENTEROLOGY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17501 GENERATIONS DR
SOUTH BEND IN
46635-1589
US

IV. Provider business mailing address

17501 GENERATIONS DR
SOUTH BEND IN
46635-1589
US

V. Phone/Fax

Practice location:
  • Phone: 574-234-0049
  • Fax: 574-251-2861
Mailing address:
  • Phone: 574-234-0049
  • Fax: 574-251-2861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: MS. MELISSA A WALKER
Title or Position: ADMINISTRATOR
Credential:
Phone: 574-234-0049