Provider Demographics
NPI:1972716082
Name:JON D. MISCH, D.O.,P.C.
Entity Type:Organization
Organization Name:JON D. MISCH, D.O.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:D
Authorized Official - Last Name:MISCH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-374-5555
Mailing Address - Street 1:13963 MORSE ST
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-9639
Mailing Address - Country:US
Mailing Address - Phone:219-374-5555
Mailing Address - Fax:219-374-6669
Practice Address - Street 1:13963 MORSE ST
Practice Address - Street 2:
Practice Address - City:CEDAR LAKE
Practice Address - State:IN
Practice Address - Zip Code:46303-9639
Practice Address - Country:US
Practice Address - Phone:219-374-5555
Practice Address - Fax:219-374-6669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2010-05-07
Deactivation Date:2010-04-08
Deactivation Code:
Reactivation Date:2010-05-07
Provider Licenses
StateLicense IDTaxonomies
IN02000900208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN226980Medicare PIN