Provider Demographics
NPI:1295397735
Name:ORTHOPEDIC AND SPORTS MEDICINE CENTER OF NORTHERN INDIANA, INC
Entity type:Organization
Organization Name:ORTHOPEDIC AND SPORTS MEDICINE CENTER OF NORTHERN INDIANA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCLAUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-970-4455
Mailing Address - Street 1:2310 CALIFORNIA RD STE A
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1228
Mailing Address - Country:US
Mailing Address - Phone:574-206-1401
Mailing Address - Fax:574-262-5183
Practice Address - Street 1:200 E JACKSON BLVD STE 130
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-3513
Practice Address - Country:US
Practice Address - Phone:574-264-0791
Practice Address - Fax:574-264-5183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300026304Medicaid