Provider Demographics
NPI:1124057419
Name:BIRNBAUM, ALAN J (MD)
Entity type:Individual
Prefix:MR
First Name:ALAN
Middle Name:J
Last Name:BIRNBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NAVARRE PL
Mailing Address - Street 2:STE 5570
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1169
Mailing Address - Country:US
Mailing Address - Phone:574-233-6620
Mailing Address - Fax:574-233-6224
Practice Address - Street 1:100 NAVARRE PL
Practice Address - Street 2:SUITE 5570
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1169
Practice Address - Country:US
Practice Address - Phone:574-233-6620
Practice Address - Fax:574-233-6224
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2007-12-14
Deactivation Date:2007-07-23
Deactivation Code:
Reactivation Date:2007-12-03
Provider Licenses
StateLicense IDTaxonomies
IN01039340207RR0500X
IN01039340A207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000226107OtherBLUE CROSS
IN190910Medicare PIN
INE93636Medicare UPIN