Healthcare Provider Details

I. General information

NPI: 1912982117
Provider Name (Legal Business Name): ERIC PAUL WOHLRAB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 N BENDIX DR STE. 500
SOUTH BEND IN
46628-3486
US

IV. Provider business mailing address

3355 DOUGLAS RD SUITE 300
SOUTH BEND IN
46635-1781
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1675
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number01047560A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number01047560A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: