Provider Demographics
NPI:1093714818
Name:BARTOSZEK, JACK S (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:S
Last Name:BARTOSZEK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4455 EDISON LAKES PKWY
Mailing Address - Street 2:UNITY MEDICAL SURGICAL HOSPITAL
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1442
Mailing Address - Country:US
Mailing Address - Phone:574-252-3085
Mailing Address - Fax:574-252-5906
Practice Address - Street 1:615 FULMER RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-6911
Practice Address - Country:US
Practice Address - Phone:574-252-3085
Practice Address - Fax:574-252-5906
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001105207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100335800AMedicaid
MIOA41009OtherBCBSM
IN000000109340OtherANTHEM NUMBER
MIN99060005Medicare PIN
MIOA41009OtherBCBSM
IN100335800AMedicaid
IN080093853 RR MED.Medicare PIN