MEDICARE: JON D MISCH D.O.

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	02000900A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000087109	OTHER	IN	ANTHEM PROVIDER #
2	90000256	OTHER	IN	BLUE CROSS/BLUE SHIELD IL

General Provider Information

NPI Number	:	1790767465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON D MISCH D.O.

Provider Business Mailing Address
First Line	:	13963 MORSE STREET
Second Line	:
City	:	CEDAR LAKE
State	:	IN
Zip	:	46303-9639
Country	:	US
Telephone Number	:	219-374-5555
Fax Number	:	219-374-6669

Provider Business Practice Location Address
First Line	:	13963 MORSE STREET
Second Line	:
City	:	CEDAR LAKE
State	:	IN
Zip	:	46303-9639
Country	:	US
Telephone Number	:	219-374-5555
Fax Number	:	219-374-6669

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

Provider Enumeration Date	:	11/17/2005
Last Update Date	:	04/19/2010

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Directions to “ JON D MISCH D.O.” Practice Location

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