Basic Information
| Provider Information | |||||||||
| NPI: | 1366777369 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLIED PHYSICIANS OF MICHIANA, LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALLIED ENT SPECIALTY CENTER | ||||||||
| 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: | 5742512151 | ||||||||
| Practice Location | |||||||||
| Address1: | 6301 UNIVERSITY COMMONS | ||||||||
| Address2: | SUITE 360 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742324800 | ||||||||
| FaxNumber: | 5742804810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2009 | ||||||||
| LastUpdateDate: | 10/02/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| 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 | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 200962980P | 05 | IN | MEDICAID | 200962980F | 05 | IN | MEDICAID |