Healthcare Provider Details

I. General information

NPI: 1124057419
Provider Name (Legal Business Name): ALAN J BIRNBAUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 12/14/2007
Certification Date:
Deactivation Date: 07/23/2007
Reactivation Date: 12/03/2007

III. Provider practice location address

100 NAVARRE PL SUITE 5570
SOUTH BEND IN
46601-1169
US

IV. Provider business mailing address

100 NAVARRE PL STE 5570
SOUTH BEND IN
46601-1169
US

V. Phone/Fax

Practice location:
  • Phone: 574-233-6620
  • Fax: 574-233-6224
Mailing address:
  • Phone: 574-233-6620
  • Fax: 574-233-6224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number01039340
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number01039340A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: