Provider Demographics
NPI:1427051796
Name:SOUTH BEND IN ENDOSCOPY ASC LLC
Entity type:Organization
Organization Name:SOUTH BEND IN ENDOSCOPY ASC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD
Mailing Address - Street 2:ATTN: L&C
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6103
Mailing Address - Country:US
Mailing Address - Phone:574-271-0893
Mailing Address - Fax:574-271-4362
Practice Address - Street 1:53830 GENERATIONS DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1557
Practice Address - Country:US
Practice Address - Phone:574-271-0893
Practice Address - Fax:574-271-4362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17-009761-1261QA1903X
IN010076261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200156540Medicaid
IN000000098200OtherBLUE CROSS INDIANA
INZP0780Medicare PIN
IN200156540Medicaid
IN15C0001071Medicare Oscar/Certification