Provider Demographics
NPI:1669421277
Name:SOUTH BEND ORTHOPAEDIC ASSOCIATES, INC.
Entity type:Organization
Organization Name:SOUTH BEND ORTHOPAEDIC ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:SIERADZKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-247-9441
Mailing Address - Street 1:53880 CARMICHAEL DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1567
Mailing Address - Country:US
Mailing Address - Phone:574-247-9441
Mailing Address - Fax:574-247-9442
Practice Address - Street 1:53880 CARMICHAEL DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1567
Practice Address - Country:US
Practice Address - Phone:574-247-9441
Practice Address - Fax:574-247-9442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50000460A207XS0106X, 207XS0117X, 207XX0004X, 2081S0010X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100220150AMedicaid
IN0429450001Medicare NSC
IN100220150AMedicaid
IN727130Medicare PIN