MEDICARE: THOMAS LARSEN MD

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	207Q00000X	Family Medicine Physician	01075173A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285998146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS LARSEN MD

Provider Business Mailing Address
First Line	:	4440 PORTAGE AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-9570
Country	:	US
Telephone Number	:	574-204-6200
Fax Number	:	574-239-1520

Provider Business Practice Location Address
First Line	:	4440 PORTAGE AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-9570
Country	:	US
Telephone Number	:	574-204-6200
Fax Number	:	574-239-1520

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2012
Last Update Date	:	09/09/2015

Similar Medicare Providers

1063020279 — ALICE CATHERINE SHAW FNP
Practice Location Address:

4440 N PORTAGE AVE
SOUTH BEND, IN
46628-9570

Practice Phone: 574-204-6200
Practice Fax:

1982694568 — DR. JAMES F BLECHL MD
Practice Location Address:

4440 NORTH PORTAGE
SOUTH BEND, IN
46628-9570

Practice Phone: 574-204-6200
Practice Fax: 574-288-1426

1063402444 — DR. THOMAS P SEASLY MD
Practice Location Address:

4440 NORTH PORTAGE AVENUE
SOUTH BEND, IN
46628-9570

Practice Phone: 574-204-6200
Practice Fax: 574-239-1520

1336166941 — DR. DAVID C BERTONCINI MD
Practice Location Address:

4440 NORTH PORTAGE AVENUE
SOUTH BEND, IN
46628-9570

Practice Phone: 574-204-6200
Practice Fax: 574-288-1426

1518316140 — DR. JONATHAN EDWARDS DITTY M.D.
Practice Location Address:

4440 PORTAGE AVE
SOUTH BEND, IN
46628-9570

Practice Phone: 574-204-6200
Practice Fax: 574-239-1520

1407206824 — MR. ROBERT CASSADY M.D.
Practice Location Address:

4440 PORTAGE AVE
SOUTH BEND, IN
46628-9570

Practice Phone: 574-204-6200
Practice Fax: 574-239-1520

Directions to “ THOMAS LARSEN MD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.