Unknown Individual – Physician Assistant, NPI 1699764308

Physician Assistant

Unknown Individual is a healthcare provider. based in South bend, Indiana. specializing in Physician Assistant. They hold a License No. 10001078A (IN). The NPI Number for Unknown Individual is 1699764308

Main info

Organization

Inactive

25 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1699764308

Phone

(574) 247-9441

Address

53880 CARMICHAEL DR

Deactivation Date

18 January 2023

Doctor Profile

Medical School Name

OTHER

Secondary Phone

5742640791

Graduation Year

2001 (25 years ago)

PAC ID

4880741255

Group Practice PAC ID

7618234121

Professional Enrollment ID

I20090422000413

Data current as of

19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience14

Completeness75

Years active:0State licenses:1Digital endpointsOther names

Provider Addresses for Unknown Individual

53880 CARMICHAEL DR
SOUTH BEND, IN 466351567
Phone: (574) 247-9441
Fax: (574) 247-9442
Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 46635)

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Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.

PAC ID: 7618234121View full group profile

Name	Specialty	State
CAROLYN M BARBUS (PA-C)	-	IN
WILLIAM BERNARD ROZZI (M.D.)	-	IN
DR. JOHN M. KELBEL (M.D.)	-	IN
HELEN M FINNAN (PT)	-	TN
ELIZABETH ANNE SULLIVAN (OT)	-	IN
MONIKA BUDACOVA (PT)	-	IN
RUTH A NOELDNER	-	IN
Unknown Individual	-	IN
ALEXANDRA IRVINE (MS, OTRL)	-	SC
DR. HENRY W. DELEEUW (M.D.)	-	IN