Basic Information
| Provider Information | |||||||||
| NPI: | 1265714778 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALLIED PHYSICIANS OF MICHIANA, LLC | ||||||||
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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: | 5742512151 | ||||||||
| Practice Location | |||||||||
| Address1: | 6301 UNIVERSITY COMMONS | ||||||||
| Address2: | SUITE 430 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5749682851 | ||||||||
| FaxNumber: | 5749682855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2011 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | ROUSSARIE | ||||||||
| AuthorizedOfficialFirstName: | SHERY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5742512100 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALLIED PHYSICIANS OF MICHIANA, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 201048070A | 05 | IN | MEDICAID |