Individual
KELLEN MASTICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
615 N MICHIGAN ST 1ST FL HOSPITALIST STE, SOUTH BEND, IN 46601-1033
(574) 647-3050
(574) 647-4320
Mailing address
3245 HEALTH DR STE 100, GRANGER, IN 46530-1380
(574) 647-1840
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
01087004A
IN
207R00000X
Internal Medicine Physician
15248
ND
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
300060015
—
IN
Enumeration date
07/10/2018
Last updated
05/01/2023
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