Provider Demographics
NPI:1508191768
Name:ALLIED PHYSICIANS OF MICHIANA, LLC
Entity Type:Organization
Organization Name:ALLIED PHYSICIANS OF MICHIANA, LLC
Other - Org Name:GENERAL & VASCULAR SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHERY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROUSSARIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-251-2100
Mailing Address - Street 1:6301 UNIVERSITY COMMONS
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1571
Mailing Address - Country:US
Mailing Address - Phone:574-251-2100
Mailing Address - Fax:574-251-2150
Practice Address - Street 1:621 MEMORIAL DR
Practice Address - Street 2:SUITE 302
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1063
Practice Address - Country:US
Practice Address - Phone:574-236-1888
Practice Address - Fax:574-236-1887
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLIED PHYSICIANS OF MICHIANA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-06
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200962980GMedicaid
IN200962980VMedicaid
IN200962980WMedicaid
IN200962980NMedicaid
IN200962980HMedicaid
IN200962980HMedicaid