Provider Demographics
NPI:1649241084
Name:SOUTH BEND MEDICAL FOUNDATION, INC
Entity Type:Organization
Organization Name:SOUTH BEND MEDICAL FOUNDATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PIPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-234-7176
Mailing Address - Street 1:530 N LAFAYETTE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1004
Mailing Address - Country:US
Mailing Address - Phone:574-204-5206
Mailing Address - Fax:574-245-0339
Practice Address - Street 1:530 N LAFAYETTE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1004
Practice Address - Country:US
Practice Address - Phone:574-204-5206
Practice Address - Fax:574-245-0339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100112700AMedicaid
1H1003494OtherTRICARE
CB4553OtherRAILROAD MEDICARE
000000097080OtherANTHEM
MI169513624Medicaid
690164004OtherRAILROAD MEDICARE
IN980010Medicare ID - Type UnspecifiedLABORATORY
MI0P27610Medicare PIN
1H1003494OtherTRICARE