NPIMap

Organization Active NPI

The South Bend Clinic LLC

  • Clinic/Center
  • South Bend, IN
National Provider Identifier
1073680419
Registry record updated Jul 10, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
Legal business name
THE SOUTH BEND CLINIC LLC
Practice address
211 N Eddy St
South Bend, IN 46617-2808
Phone
(574) 299-2450
Fax
(574) 299-2415
NPI assigned
Nov 29, 2006
Last updated
Jul 10, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 10, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Paul J Meyer
Title
Executive Director
Phone
(574) 237-9201

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X NU Primary
Ambulatory Surgical Clinic/Center 261QA1903X IN
Clinical Medical Laboratory 291U00000X 15D0357414 IN
Durable Medical Equipment & Medical Supplies 332B00000X NU

Addresses

Primary practice location

211 N Eddy St
South Bend, IN 46617-2808

Mailing address

6301 University Commons Ste 230
South Bend, IN 46635-1590
Phone (574) 251-2115

Other practice location 1

6301 University Commons Ste 230
South Bend, IN 46635-1590
Phone (574) 251-2115

Other identifiers 1

IdentifierTypeStateIssuer
100442630MedicaidIN

Other names 1

  • South Bend Clinic Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN, MI5 enrollments

Enrollment records 5

Enrollment IDStateProvider typePAC IDDetails
O20040412000439 IN Part B Supplier - Clinic/Group Practice 3779577937 Receives reassigned benefits from 211 practitioners
6 other NPIs on this enrollment
Practice locations: South Bend, IN; Walkerton, IN; Elkhart, IN; Goshen, IN; Granger, IN; Mishawaka, IN; New Carlisle, IN; Notre Dame, IN…
O20070720000001 IN Part B Supplier - Ambulatory Surgical Center 3779577937 1 other NPI on this enrollment
Practice locations: South Bend, IN
O20071025000007 MI Part B Supplier - Clinic/Group Practice 3779577937 Receives reassigned benefits from 1 practitioner
Practice locations: Berrien Springs, MI
O20100930013481 IN DME Supplier - Multi-Specialty - PhysicianDME Supplier - Pharmacy 3779577937 1 other NPI on this enrollment
Practice locations: South Bend, IN
O20110624000518 IN Part B Supplier - Independent Clinical Laboratory 3779577937 Practice locations: South Bend, IN

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Care Compare: Ambulatory surgical center

Medicare Care Compare
Listed as
The South Bend Clinic LLPCCN 15C0001007
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory

Locations

52500 Fir Rd
Granger, IN 46530
Phone (574) 204-7050

1802 Day Rd
Mishawaka, IN 46545
Phone (574) 204-7200

4440 Portage Rd
South Bend, IN 46628
Phone (574) 204-6200

6301 University Commons
Ste 320
South Bend, IN 46635
Phone (574) 247-4667

6301 University Commons
Ste 360
South Bend, IN 46635
Phone (574) 232-4800

9045 US Highway 31
Ste 3
Berrien Springs, MI 49103
Phone (269) 471-9702

Practitioners & affiliated clinicians

Practitioners 231

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 231

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1164758400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1720569600000",
    "number": "1073680419",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6301 UNIVERSITY COMMONS STE 230",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466351590",
            "telephone_number": "574-251-2115",
            "fax_number": "574-251-2150"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "211 N EDDY ST",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466172808",
            "telephone_number": "574-299-2450",
            "fax_number": "574-299-2415"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "6301 University Commons Ste 230",
            "address_purpose": "LOCATION",
            "city": "South Bend",
            "state": "IN",
            "postal_code": "466351590",
            "country_code": "US",
            "telephone_number": "574-251-2115",
            "fax_number": "574-251-2150",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "THE SOUTH BEND CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-29",
        "last_updated": "2024-07-10",
        "certification_date": "2024-07-10",
        "status": "A",
        "authorized_official_last_name": "MEYER",
        "authorized_official_first_name": "PAUL",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "574-237-9201",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "IN",
            "license": null,
            "primary": false
        },
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "IN",
            "license": "15D0357414",
            "primary": false
        },
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100442630",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "South Bend Clinic",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "South Bend Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in South Bend, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 10, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.