Provider Demographics
NPI:1952721185
Name:INDIANA UNIVERSITY SOUTH BEND HEALTH & WELLNESS CENTER
Entity Type:Organization
Organization Name:INDIANA UNIVERSITY SOUTH BEND HEALTH & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEAN AND PROFESSOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN; PHD; PHCNS-BC
Authorized Official - Phone:574-520-5557
Mailing Address - Street 1:941 20TH STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46634-7111
Mailing Address - Country:US
Mailing Address - Phone:574-520-5557
Mailing Address - Fax:574-520-5042
Practice Address - Street 1:941 20TH STREET
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46634-7111
Practice Address - Country:US
Practice Address - Phone:574-520-5557
Practice Address - Fax:574-520-5042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28076706A164W00000X
IN28156667A164W00000X
IN01046709207R00000X
302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Multi-Specialty