Provider Demographics
NPI:1578558458
Name:MISHAWAKA ORTHOPEDICS AND SPORTS MEDICINE P C
Entity Type:Organization
Organization Name:MISHAWAKA ORTHOPEDICS AND SPORTS MEDICINE P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MCDONALD
Authorized Official - Last Name:WARE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:574-271-5151
Mailing Address - Street 1:270 E DAY RD
Mailing Address - Street 2:STE 200
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3444
Mailing Address - Country:US
Mailing Address - Phone:574-271-5151
Mailing Address - Fax:574-271-5175
Practice Address - Street 1:270 E DAY RD
Practice Address - Street 2:STE 200
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3444
Practice Address - Country:US
Practice Address - Phone:574-271-5151
Practice Address - Fax:574-271-5175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50003916A207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200248370AMedicaid
GACE8821OtherRR MEDICARE
IN000000104753OtherBC/BS
IN0804860001Medicare NSC
IN131980Medicare PIN