NPIMap

Organization Active NPI

The South Bend Clinic, LLC

  • Anesthesiology Physician
  • South Bend, IN
National Provider Identifier
1487307492
Registry record updated Mar 7, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Anesthesiology PhysicianTaxonomy code 207L00000X
Legal business name
THE SOUTH BEND CLINIC, LLC
Practice address
211 N Eddy St
South Bend, IN 46617-3096
Phone
(574) 239-1567
NPI assigned
Jan 31, 2022
Last updated
Mar 7, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 7, 2022

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

Authorized official

Name
Kelly Macken-Marble
Title
Ceo
Phone
(574) 239-1567

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Anesthesiology Physician 207L00000X 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) 239-1567

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN

Enrollment records 1

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
This NPI is an additional NPI on the enrollment
Practice locations: South Bend, IN; Walkerton, IN; Elkhart, IN; Goshen, IN; Granger, IN; Mishawaka, IN; New Carlisle, IN; Notre Dame, IN…

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory
Tax ID family
South Bend Clinic LLP9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

Locations

234 Waterfall Dr
Ste C
Elkhart, IN 46516
Phone (574) 237-9217

500 Arcade Ave
Elkhart, IN 46514
Phone (260) 296-6468

700 E Beardsley Ave
Elkhart, IN 46514
Phone (574) 206-8010

1233 E University Dr
#C
Granger, IN 46530
Phone (574) 247-3937

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

215 W 4th St
Mishawaka, IN 46544
Phone (219) 259-2431

303 S Main St
Ste 217
Mishawaka, IN 46544
Phone (574) 204-6700

8984 E US Highway 20
New Carlisle, IN 46552
Phone (574) 654-8490

475 N Niles Ave
South Bend, IN 46617
Phone (574) 246-4123

6301 University Commons
Ste 380
South Bend, IN 46635

837 Cedar St
Ste 350
South Bend, IN 46617
Phone (574) 234-9555

Interoperability endpoints

  • FHIR API: https://epicproxy.et1296.epichosted.com/APIProxyPRD/api/FHIR/R4/

Practitioners & affiliated clinicians

Practitioners 200

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 200

NPI Registry JSON

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

{
    "created_epoch": "1643587200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1646611200000",
    "number": "1487307492",
    "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": "574-239-1567"
        },
        {
            "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": "574-239-1567"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE SOUTH BEND CLINIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-01-31",
        "last_updated": "2022-03-07",
        "certification_date": "2022-03-07",
        "status": "A",
        "authorized_official_last_name": "MACKEN-MARBLE",
        "authorized_official_first_name": "KELLY",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "574-239-1567"
    },
    "taxonomies": [
        {
            "code": "207L00000X",
            "taxonomy_group": "",
            "desc": "Anesthesiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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 Mar 7, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.