Provider Demographics
NPI:1225095912
Name:BRENDLE, MICHAEL T (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:BRENDLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 W EDISON RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-2784
Mailing Address - Country:US
Mailing Address - Phone:574-258-1100
Mailing Address - Fax:574-258-1101
Practice Address - Street 1:620 W EDISON RD
Practice Address - Street 2:SUITE 110
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-2784
Practice Address - Country:US
Practice Address - Phone:574-258-1100
Practice Address - Fax:574-258-1101
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010385122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100319770Medicaid
IN100319770Medicaid
INF18393Medicare UPIN