Organization
PRA MEDICAL INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
YUPIDA PRASERTWANITCH MD (OWNER)
(574) 273-6546
Entity
Organization
Contact information
Practice address
211 N EDDY ST, SOUTH BEND, IN 46617-2808
(574) 299-2450
(574) 273-6546
Mailing address
PO BOX 182, MISHAWAKA, IN 46546-0182
(574) 273-6546
(574) 273-5295
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
01027483A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3521474218
EIN
IN
Enumeration date
03/07/2007
Last updated
08/22/2020
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