Provider Demographics
NPI:1043425564
Name:ORTHOPEDIC AND SPORTS MEDICINE CENTER OF NORTHERN INDIANA, INC.
Entity Type:Organization
Organization Name:ORTHOPEDIC AND SPORTS MEDICINE CENTER OF NORTHERN INDIANA, INC.
Other - Org Name:ORTHOPEDIC & SPORTS MEDICINE CENTER (OSMC)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCLAUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-264-0791
Mailing Address - Street 1:2310 CALIFORNIA RD STE A
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1228
Mailing Address - Country:US
Mailing Address - Phone:574-264-0791
Mailing Address - Fax:574-262-9650
Practice Address - Street 1:2310 CALIFORNIA RD STE A
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1228
Practice Address - Country:US
Practice Address - Phone:574-264-0791
Practice Address - Fax:574-262-9650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50000745A335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100111780AMedicaid
IN0235070001Medicare NSC
IN100111780AMedicaid