Provider Demographics
NPI:1154663763
Name:ALEXANDER C. GATZIMOS MD JD
Entity Type:Organization
Organization Name:ALEXANDER C. GATZIMOS MD JD
Other - Org Name:MICHIANA ADULT MEDICAL SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:C
Authorized Official - Last Name:GATZIMOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, JD
Authorized Official - Phone:574-249-8663
Mailing Address - Street 1:2050 E IRELAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-2909
Mailing Address - Country:US
Mailing Address - Phone:574-222-2359
Mailing Address - Fax:574-222-2365
Practice Address - Street 1:2050 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2909
Practice Address - Country:US
Practice Address - Phone:574-222-2359
Practice Address - Fax:574-222-2365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-21
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036818A207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND95574Medicaid
INDP5574Medicare UPIN