Provider Demographics
NPI:1538257167
Name:THE SOUTH BEND CLINIC LLP
Entity type:Organization
Organization Name:THE SOUTH BEND CLINIC LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:E
Authorized Official - Last Name:MACKEN-MARBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-237-9201
Mailing Address - Street 1:PO BOX 715223
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45271-5223
Mailing Address - Country:US
Mailing Address - Phone:574-299-2450
Mailing Address - Fax:574-299-2415
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2808
Practice Address - Country:US
Practice Address - Phone:574-246-8816
Practice Address - Fax:574-237-9309
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH BEND CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200266980AMedicaid