Basic Information
| Provider Information | |||||||||
| NPI: | 1841215738 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN INDIANA OPTOMETRISTS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4123 S MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466142545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742919200 | ||||||||
| FaxNumber: | 5742994423 | ||||||||
| Practice Location | |||||||||
| Address1: | 4123 S MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466142545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742919200 | ||||||||
| FaxNumber: | 5742994423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | PESCHKE | ||||||||
| AuthorizedOfficialFirstName: | TERRI | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5742919200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18001810 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1548296718 | 01 | IN | INDIVIDUAL NPI | OTHER | 200831530 | 05 | IN | MEDICAID |