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	261QE0800X	Endoscopy Clinic/Center	010076	IN
2	261QA1903X	Ambulatory Surgical Clinic/Center	17-009761-1	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
2	000000098200	OTHER	IN	BLUE CROSS INDIANA

General Provider Information

NPI Number	:	1427051796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH BEND IN ENDOSCOPY ASC LLC

Provider Business Mailing Address
First Line	:	1A BURTON HILLS BLVD
Second Line	:	ATTN: L&C
City	:	NASHVILLE
State	:	TN
Zip	:	37215-6103
Country	:	US
Telephone Number	:	574-271-0893
Fax Number	:	574-271-4362

Provider Business Practice Location Address
First Line	:	53830 GENERATIONS DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46635-1557
Country	:	US
Telephone Number	:	574-271-0893
Fax Number	:	574-271-4362

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JEFFREY SNODGRASS
Credential	:
Telephone Number	:	615-665-1283

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	06/28/2022

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Directions to “SOUTH BEND IN ENDOSCOPY ASC LLC ” Practice Location

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