Provider Demographics
NPI:1134281546
Name:SOUTH BEND IN ENDOSCOPY ASC LLC
Entity Type:Organization
Organization Name:SOUTH BEND IN ENDOSCOPY ASC LLC
Other - Org Name:MICHIANA ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MANAGER OF LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:53830 GENERATIONS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1557
Mailing Address - Country:US
Mailing Address - Phone:574-271-0839
Mailing Address - Fax:
Practice Address - Street 1:53830 GENERATIONS DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1557
Practice Address - Country:US
Practice Address - Phone:574-271-0839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical