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General NPI Number Information
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NPI Number | 1396729893
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Entity Type | Individual
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Provider Name | JEROME RUSCEAK SKELLY M.D.
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Gender | Male
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Dates
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Enumeration Date | 11/30/2005
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Last Update Date | 12/18/2024
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Provider Practice Location Address
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Address Line | 1815 E IRELAND RD
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City | SOUTH BEND
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State | IN
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Zip | 46614-2845
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Country | US
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Telephone | 574-647-1700
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Fax | 574-647-1993
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Provider Business Mailing Address
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Address Line | 3245 HEALTH DR STE 100
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City | GRANGER
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State | IN
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Zip | 46530-1380
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Country | US
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Telephone | 574-647-1610
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | 01049640A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 01049640A
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License Number State | IN
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