Basic Information
| Provider Information | |||||||||
| NPI: | 1619261955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHWALBE | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2102 E INWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466142443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742992400 | ||||||||
| FaxNumber: | 5742992410 | ||||||||
| Practice Location | |||||||||
| Address1: | 2102 E INWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466142443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742992400 | ||||||||
| FaxNumber: | 5742992410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2011 | ||||||||
| LastUpdateDate: | 05/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01074578A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201252720 | 05 | IN | MEDICAID |