MEDICARE: SOUTH BEND IN ENDOSCOPY ASC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1134281546
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH BEND IN ENDOSCOPY ASC LLC

Provider Business Mailing Address
First Line	:	53830 GENERATIONS DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46635-1557
Country	:	US
Telephone Number	:	574-271-0839
Fax Number	:

Provider Business Practice Location Address
First Line	:	53830 GENERATIONS DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46635-1557
Country	:	US
Telephone Number	:	574-271-0839
Fax Number	:

Authorized Official
Title or Position	:	CHIEF MANAGER OF LLC
Name	:	MR. KEN P. MCDONALD
Credential	:
Telephone Number	:	615-665-1283

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	01/09/2008

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