Basic Information
Provider Information | |||||||||
NPI: | 1376841395 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEMORIAL HOSPITAL OF SOUTH BEND | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEMORIAL EPWORTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 615 N MICHIGAN ST | ||||||||
Address2: |   | ||||||||
City: | SOUTH BEND | ||||||||
State: | IN | ||||||||
PostalCode: | 466011033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5746477167 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 420 N NILES AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTH BEND | ||||||||
State: | IN | ||||||||
PostalCode: | 466171918 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5746478400 | ||||||||
FaxNumber: | 5746478410 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/01/2011 | ||||||||
LastUpdateDate: | 02/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COSTELLO | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
AuthorizedOfficialTelephone: | 5746473549 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 005053 | IN | Y |   | Hospital Units | Psychiatric Unit |   |
ID Information
ID | Type | State | Issuer | Description | 100269890B | 05 | IN |   | MEDICAID |