Provider Demographics
NPI:1770613622
Name:PRA MEDICAL INC
Entity type:Organization
Organization Name:PRA MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YUPIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRASERTWANITCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-273-6546
Mailing Address - Street 1:PO BOX 182
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46546-0182
Mailing Address - Country:US
Mailing Address - Phone:574-273-6546
Mailing Address - Fax:574-273-5295
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:574-299-2450
Practice Address - Fax:574-273-6546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027483A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN3521474218OtherEIN
IN736820Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER