Ebonee L Davis, MD
Individual provider Active NPI Internal Medicine Physician · South Bend, IN
NPI 1295725646 · NPPES record last updated Aug 2, 2016
Key facts
- NPI
- 1295725646
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Internal Medicine Physician 207R00000X
- License
- 01060624A (IN)
- Practice address
- 211 N Eddy St
South Bend, IN 46617-2808 - Phone
- (574) 237-9340
- Fax
- (574) 239-1474
- NPI assigned
- Oct 26, 2005
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 3
Hospital & facility affiliations 9
Medicare Care Compare profile
- Specialty
- Internal Medicine
- Education
- Wayne State University School of Medicine, 1997
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- The South Bend Clinic LLC
Practice addresses (Care Compare)
211 N Eddy St
South Bend, IN 46617-2808
Phone (574) 234-8161
52500 Fir Rd
Granger, IN 46530-8579
Phone (574) 271-0700
Hospital & facility affiliations
- Saint Joseph Vna Home Care
- Elara Caring
- Aunova Home Care LLC
- Memorial Hospital of South Bend
- Saint Joseph Regional Medical Center
- Lakeland Hospital, St Joseph
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IN
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20050909000834 | IN | Practitioner - Internal Medicine | 1759313786 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 01060624A | IN | MD | Internal Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| The South Bend Clinic LLC | Current |
Accepting new patients | |
| The South Bend Clinic, LLC | Current |
Accepting new patients |
Locations
211 N Eddy St
South Bend, IN 46617
Phone (574) 237-9331
Interoperability endpoints
- edavis253099@dulyhealthandcare.direct-ci.com
- https://epicproxy.et1296.epichosted.com/APIProxyPRD/api/FHIR/R4/
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | 01060624A | IN | Yes |
Addresses
Primary practice location
211 N Eddy St
South Bend, IN 46617-2808
Mailing address
211 N Eddy St
South Bend, IN 46617-2808
Phone (574) 237-9340
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 200528010 | Medicaid | IN |
NPI Registry JSON
{
"created_epoch": "1130284800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1470096000000",
"number": "1295725646",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "211 N EDDY ST",
"city": "SOUTH BEND",
"state": "IN",
"postal_code": "466172808",
"telephone_number": "574-237-9340",
"fax_number": "574-239-1474"
},
{
"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": "574-237-9340",
"fax_number": "574-239-1474"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DAVIS",
"first_name": "EBONEE",
"middle_name": "L",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2005-10-26",
"last_updated": "2016-08-02",
"status": "A"
},
"taxonomies": [
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": "IN",
"license": "01060624A",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "200528010",
"state": "IN"
}
],
"endpoints": [],
"other_names": []
}Other providers in South Bend, IN
- Bradley A Davis
- Chyanne Alexis Davis
- Clara M Davis
- Courtney Davis
- Desiree Davis
- Glen A Davis
- Hillary Davis
- Jacinta R Davis
- Kierris Davis
- Trevor Day
All providers in South Bend, IN · Internal Medicine Physician in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 2, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.