Provider Demographics
NPI:1013907781
Name:CREDI, ROBERT G (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
Last Name:CREDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:621 MEMORIAL DR STE 502
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1075
Practice Address - Country:US
Practice Address - Phone:574-647-5875
Practice Address - Fax:574-647-5878
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044047A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200078980Medicaid
IN236040415OtherMEDICARE PTAN
INF57217Medicare UPIN
INZP0080Medicare PIN