Basic Information
| Provider Information | |||||||||
| NPI: | 1164624649 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHIANA PHYSICAL MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 WINSTED DR | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465264696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745344648 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2310 CALIFORNIA RD | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465141228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742647085 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 12/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | SZYNAL | ||||||||
| AuthorizedOfficialFirstName: | JOAN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5742647085 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.