Provider Demographics
NPI:1144580150
Name:SAINT JOSEPH REGIONAL MEDICAL CENTER-SOUTH BEND CAMPUS, INC.
Entity Type:Organization
Organization Name:SAINT JOSEPH REGIONAL MEDICAL CENTER-SOUTH BEND CAMPUS, INC.
Other - Org Name:FAMILY MEDICINE FACULTY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-335-5000
Mailing Address - Street 1:707 CEDAR ST, STE 200
Mailing Address - Street 2:FAMILY MEDICINE FACULTY PHYSICIANS (PROVIDER SERVICES)
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0741
Practice Address - Street 1:611 E DOUGLAS RD, STE 406
Practice Address - Street 2:FAMILY MEDICINE FACULTY PHYSICIANS
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1468
Practice Address - Country:US
Practice Address - Phone:574-335-6580
Practice Address - Fax:574-335-0818
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRINITY HEALTH CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-23
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100382210CMedicaid
INCC0460OtherRAILROAD MEDICARE
INCC0460OtherRAILROAD MEDICARE
IN100382210CMedicaid