Provider Demographics
NPI:1558568667
Name:NORTHERN INDIANA REHABILITATION MEDICINE, INC.
Entity Type:Organization
Organization Name:NORTHERN INDIANA REHABILITATION MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:L
Authorized Official - Last Name:YU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-232-2222
Mailing Address - Street 1:206 E BARTLETT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1016
Mailing Address - Country:US
Mailing Address - Phone:574-232-2222
Mailing Address - Fax:574-232-2224
Practice Address - Street 1:206 E BARTLETT ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1016
Practice Address - Country:US
Practice Address - Phone:574-232-2222
Practice Address - Fax:574-232-2224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036492208100000X, 2081P0004X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC24552Medicare UPIN
IN16-5680Medicare ID - Type Unspecified