Healthcare Provider Details

I. General information

NPI: 1659864387
Provider Name (Legal Business Name): MARY REGINA FEEKS LACOURSIERE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N MICHIGAN ST 5TH FL
SOUTH BEND IN
46601-1033
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-7275
  • Fax: 574-647-3696
Mailing address:
  • Phone: 574-647-2129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number02007852A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: