Healthcare Provider Details

I. General information

NPI: 1801300330
Provider Name (Legal Business Name): ALEJANDRO MIKELONIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ALEX MIKELONIS PA-C

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N MICHIGAN ST STE 306
SOUTH BEND IN
46601-1079
US

IV. Provider business mailing address

710 N NILES AVE
SOUTH BEND IN
46617-1924
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-6500
  • Fax: 574-647-6518
Mailing address:
  • Phone: 574-647-1610
  • Fax: 574-237-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002386A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: