Healthcare Provider Details

I. General information

NPI: 1710977319
Provider Name (Legal Business Name): BRENT W MOHR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 07/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

IV. Provider business mailing address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

V. Phone/Fax

Practice location:
  • Phone: 574-237-9331
  • Fax: 574-239-1495
Mailing address:
  • Phone: 574-237-9331
  • Fax: 574-239-1495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number01040434A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: