Provider Demographics
NPI:1225605207
Name:NURSE PRACTITIONER SERVICES OF MICHIANA
Entity Type:Organization
Organization Name:NURSE PRACTITIONER SERVICES OF MICHIANA
Other - Org Name:NURSE PRACTITIONER SERVICES OF MICHIANA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KERTES
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHANIE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:574-274-3925
Mailing Address - Street 1:2901 E BRISTOL ST STE B
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-4385
Mailing Address - Country:US
Mailing Address - Phone:574-622-1522
Mailing Address - Fax:833-310-2090
Practice Address - Street 1:2901 E BRISTOL ST STE B
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-4385
Practice Address - Country:US
Practice Address - Phone:574-622-1522
Practice Address - Fax:833-310-2090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-08
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201317770Medicaid