Provider Demographics
NPI:1255549812
Name:FORNALIK, HUBERT (MD)
Entity type:Individual
Prefix:
First Name:HUBERT
Middle Name:
Last Name:FORNALIK
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 1:100 E WAYNE ST STE 510
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-2394
Mailing Address - Country:US
Mailing Address - Phone:574-334-5400
Mailing Address - Fax:
Practice Address - Street 1:5340 HOLY CROSS PKWY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1470
Practice Address - Country:US
Practice Address - Phone:574-237-1328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37108207V00000X
IN01067752A207V00000X, 207VX0201X
PAMT181806207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200978000Medicaid
INM400019246Medicare PIN
IN188940011Medicare PIN