Basic Information
| Provider Information | |||||||||
| NPI: | 1538257167 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE SOUTH BEND CLINIC LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 715223 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452715223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742992450 | ||||||||
| FaxNumber: | 5742992415 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 N EDDY ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466172808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742468816 | ||||||||
| FaxNumber: | 5742379309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | MACKEN-MARBLE | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5742379201 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH BEND CLINIC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 200266980A | 05 | IN | MEDICAID |