Provider Demographics
NPI:1396764270
Name:SOUTHE, PATRICK E (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:E
Last Name:SOUTHE
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:574-647-1825
Practice Address - Street 1:6913 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8039
Practice Address - Country:US
Practice Address - Phone:574-647-1550
Practice Address - Fax:574-243-4306
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042581A207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000782901OtherANTHEM
IN01042581BOtherCSR
IN01042581AOtherINDIANA LICENSE
IN100385740Medicaid
IN01042581BOtherCSR
IN236040003Medicare PIN