Provider Demographics
NPI:1902200298
Name:ALLIED PHYSICIANS OF MICHIANA, LLC
Entity Type:Organization
Organization Name:ALLIED PHYSICIANS OF MICHIANA, LLC
Other - Org Name:ALLIED BONE AND JOINT
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 1:1919 LAKE AVE
Practice Address - Street 2:SUITE 107B
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7830
Practice Address - Country:US
Practice Address - Phone:574-540-2500
Practice Address - Fax:574-540-2570
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLIED PHYSICIANS OF MICHIANA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200962980Medicaid
IN261408Medicare PIN