Provider Demographics
NPI:1972776938
Name:MISHAWAKA CLINIC, P.C.
Entity Type:Organization
Organization Name:MISHAWAKA CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:REIDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-254-0800
Mailing Address - Street 1:303 S. MAIN ST.
Mailing Address - Street 2:SUITE 212
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544
Mailing Address - Country:US
Mailing Address - Phone:574-254-0800
Mailing Address - Fax:574-254-0812
Practice Address - Street 1:303 S. MAIN ST.
Practice Address - Street 2:SUITE 212
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544
Practice Address - Country:US
Practice Address - Phone:574-254-0800
Practice Address - Fax:574-254-0812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1497794010OtherNPI
IN1497794010OtherNPI