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General NPI Number Information
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NPI Number | 1700112224
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Entity Type | Organization
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Legal Business Name | SOUTH BEND PSYCHIATRY LLC
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Dates
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Enumeration Date | 10/19/2009
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Last Update Date | 09/15/2021
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Provider Practice Location Address
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Address Line | 1800 N OAK DR
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City | PLYMOUTH
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State | IN
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Zip | 46563-3406
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Country | US
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Telephone | 574-303-5375
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Fax |
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Provider Business Mailing Address
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Address Line | 11106 BIRCH LAKE DR
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City | GRANGER
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State | IN
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Zip | 46530-6032
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Country | US
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Telephone | 574-303-5375
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | DR. MALLIKARJUN PATTA
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Credential | MD
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Telephone | 574-303-5375
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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