=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093714818
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK S. BARTOSZEK D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2005
-----------------------------------------------------
Last Update Date | 09/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 FULMER RD
-----------------------------------------------------
City | MISHAWAKA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46544-6911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-252-3085
-----------------------------------------------------
Fax | 574-252-5906
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4455 EDISON LAKES PKWY UNITY MEDICAL SURGICAL HOSPITAL
-----------------------------------------------------
City | MISHAWAKA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46545-1442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-252-3085
-----------------------------------------------------
Fax | 574-252-5906
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 02001105
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------