Provider Demographics
NPI:1811300817
Name:FATH, COLIN TALANDA (MD)
Entity type:Individual
Prefix:DR
First Name:COLIN
Middle Name:TALANDA
Last Name:FATH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 ARCADE AVE STE 320
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2477
Practice Address - Country:US
Practice Address - Phone:574-523-7900
Practice Address - Fax:574-523-7909
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-10033208600000X
KY52660208600000X, 2086S0102X
IN01091291A208600000X, 2086S0102X
MI43015056252086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300055631Medicaid