MEDICARE: ORTHOPEDIC AND SPORTS MEDICINE CENTER OF NORTHERN INDIANA, INC

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	335E00000X	Prosthetic/Orthotic Supplier

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	:	1295397735
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOPEDIC AND SPORTS MEDICINE CENTER OF NORTHERN INDIANA, INC

Provider Business Mailing Address
First Line	:	2310 CALIFORNIA RD STE A
Second Line	:
City	:	ELKHART
State	:	IN
Zip	:	46514-1228
Country	:	US
Telephone Number	:	574-206-1401
Fax Number	:	574-262-5183

Provider Business Practice Location Address
First Line	:	200 E JACKSON BLVD STE 130
Second Line	:
City	:	ELKHART
State	:	IN
Zip	:	46516-3513
Country	:	US
Telephone Number	:	574-264-0791
Fax Number	:	574-264-5183

Authorized Official
Title or Position	:	CAO
Name	:	ROBIN S. MCLAUGHLIN
Credential	:
Telephone Number	:	574-970-4455

Provider Enumeration Date	:	07/05/2019
Last Update Date	:	07/05/2019

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