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General NPI Number Information
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NPI Number | 1720188956
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Entity Type | Individual
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Provider Name | LILLIAN SANDIC JARDINE MD
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Gender | Female
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Dates
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Enumeration Date | 09/25/2006
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Last Update Date | 06/09/2015
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Provider Practice Location Address
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Address Line | 5735 S IRONWOOD RD
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City | SOUTH BEND
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State | IN
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Zip | 46614-9668
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Country | US
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Telephone | 574-299-4847
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Fax | 574-299-9073
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Provider Business Mailing Address
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Address Line | 5735 S IRONWOOD RD
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City | SOUTH BEND
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State | IN
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Zip | 46614-9668
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Country | US
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Telephone | 574-299-4847
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Fax | 574-299-9073
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 01061418A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4301072875
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License Number State | MI
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