Basic Information
| Provider Information | |||||||||
| NPI: | 1013310192 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLIED PHYSICIANS OF MICHIANA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALLIED BONE AND JOINT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6301 UNIVERSITY COMMONS | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742512100 | ||||||||
| FaxNumber: | 5742512150 | ||||||||
| Practice Location | |||||||||
| Address1: | 2349 LAKE AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465637835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745402500 | ||||||||
| FaxNumber: | 5745402570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2014 | ||||||||
| LastUpdateDate: | 12/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | ROUSSARIE | ||||||||
| AuthorizedOfficialFirstName: | SHERY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5742512100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALLIED PHYSICIANS OF MICHIANA, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 4108460008 | 01 | IN | MEDICARE PTAN | OTHER | 201236170 | 05 | IN | MEDICAID |