Healthcare Provider Details

I. General information

NPI: 1427051796
Provider Name (Legal Business Name): SOUTH BEND IN ENDOSCOPY ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53830 GENERATIONS DR
SOUTH BEND IN
46635-1557
US

IV. Provider business mailing address

1A BURTON HILLS BLVD ATTN: L&C
NASHVILLE TN
37215-6103
US

V. Phone/Fax

Practice location:
  • Phone: 574-271-0893
  • Fax: 574-271-4362
Mailing address:
  • Phone: 574-271-0893
  • Fax: 574-271-4362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number17-009761-1
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number010076
License Number StateIN

VIII. Authorized Official

Name: MR. JEFFREY SNODGRASS
Title or Position: PRESIDENT
Credential:
Phone: 615-665-1283