=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134534456
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEMORIAL HOSPITAL OF SOUTH BEND, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2014
-----------------------------------------------------
Last Update Date | 09/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 E MADISON ST
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46617-2322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-647-8400
-----------------------------------------------------
Fax | 574-647-8410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 615 N MICHIGAN ST
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP/CFO
-----------------------------------------------------
Name | MR. JEFFERY P COSTELLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 574-647-3549
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------