Provider Demographics
NPI:1720188956
Name:JARDINE, LILLIAN SANDIC (MD)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:SANDIC
Last Name:JARDINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5735 S IRONWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-9668
Mailing Address - Country:US
Mailing Address - Phone:574-299-4847
Mailing Address - Fax:574-299-9073
Practice Address - Street 1:5735 S IRONWOOD RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-9668
Practice Address - Country:US
Practice Address - Phone:574-299-4847
Practice Address - Fax:574-299-9073
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061418A207Q00000X
MI4301072875207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1720188956Medicaid
MI1720188956Medicaid