Provider Demographics
NPI:1073680419
Name:THE SOUTH BEND CLINIC LLC
Entity Type:Organization
Organization Name:THE SOUTH BEND CLINIC LLC
Other - Org Name:SOUTH BEND CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-237-9201
Mailing Address - Street 1:PO BOX 1755
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46634-1755
Mailing Address - Country:US
Mailing Address - Phone:574-299-2450
Mailing Address - Fax:574-299-2415
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2808
Practice Address - Country:US
Practice Address - Phone:574-299-2450
Practice Address - Fax:574-299-2415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 332B00000X
IN261QA1903X
IN15D0357414291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100442630Medicaid
IN0329570001Medicare NSC
IN146470Medicare PIN