NPIMap

Individual provider Active NPI

Rachelina Portolese Kvietkus, M.D.

  • Internal Medicine Physician
  • South Bend, IN
National Provider Identifier
1376586420
Registry record updated Oct 22, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
01045522 Issued in IN
Practice address
211 N Eddy St
South Bend, IN 46617-3096
Phone
(574) 237-9340
Fax
(574) 239-1474
NPI assigned
Jun 14, 2006
Last updated
Oct 22, 2018By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 22, 2018

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 01045522 IN Primary

Addresses

Primary practice location

211 N Eddy St
South Bend, IN 46617-3096

Mailing address

211 N Eddy St
South Bend, IN 46617-3096
Phone (574) 237-9340

Other identifiers 3

IdentifierTypeStateIssuer
P01306109OtherINRR MEDICARE
000000772015OtherINBCBS BMG GOSHEN
200108300MedicaidIN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20090921000010 IN Practitioner - Internal Medicine 7315093192 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
Indiana University School of Medicine, 1993
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
The South Bend Clinic LLCGroup PAC ID 3779577937, 171 clinicians

Practice addresses (Care Compare)

211 N Eddy St
South Bend, IN 46617-2808
Phone (574) 234-8161

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
01045522INMDInternal Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
The South Bend Clinic LLC CurrentSince Oct 1, 2018 Accepting new patients
The South Bend Clinic, LLC CurrentSince Oct 1, 2018 Accepting new patients

Locations

5215 Holy Cross Pkwy
Mishawaka, IN 46545
Phone (574) 335-2443

211 N Eddy St
South Bend, IN 46617
Phone (574) 237-9331

Interoperability endpoints

  • FHIR API: https://epicproxy.et1296.epichosted.com/APIProxyPRD/api/FHIR/R4/
  • Direct secure messaging: rkvietkus254031@dulyhealthandcare.direct-ci.com

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Heart to Heart Hospice of Eastern Indiana, LLCElkhart, IN, CCN 151561 Hospice Contracted Managing Employee Mar 1, 2021

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 11

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1150243200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1540166400000",
    "number": "1376586420",
    "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": "466173096",
            "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": "466173096",
            "telephone_number": "574-237-9340",
            "fax_number": "574-239-1474"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KVIETKUS",
        "first_name": "RACHELINA",
        "middle_name": "PORTOLESE",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-06-14",
        "last_updated": "2018-10-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "IN",
            "license": "01045522",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "P01306109",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS BMG GOSHEN",
            "identifier": "000000772015",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200108300",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in South Bend, IN

Sources for this page

Verify at the official NPI Registry.