=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154832178
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLIED PHYSICIANS OF MICHIANA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2017
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 E DOUGLAS RD STE 308
-----------------------------------------------------
City | MISHAWAKA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46545-1465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-236-1888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6301 UNIVERSITY COMMONS STE 230
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46635-1590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SHERY ROUSSARIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 574-251-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------