Healthcare Provider Details

I. General information

NPI: 1669421277
Provider Name (Legal Business Name): SOUTH BEND ORTHOPAEDIC ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53880 CARMICHAEL DR
SOUTH BEND IN
46635-1567
US

IV. Provider business mailing address

53880 CARMICHAEL DR
SOUTH BEND IN
46635-1567
US

V. Phone/Fax

Practice location:
  • Phone: 574-247-9441
  • Fax: 574-247-9442
Mailing address:
  • Phone: 574-247-9441
  • Fax: 574-247-9442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number50000460A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number50000460A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number50000460A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number50000460A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number50000460A
License Number StateIN

VIII. Authorized Official

Name: JAMES P SIERADZKI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 574-247-9441