1740268796 NPI number — ORTHOPAEDICS NORTHEAST PC

Table of content: (NPI 1740268796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740268796 NPI number — ORTHOPAEDICS NORTHEAST PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOPAEDICS NORTHEAST PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DBA ONE ANESTHESIA SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740268796
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5052 N CLINTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46825-5822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-484-8551
Provider Business Mailing Address Fax Number:
260-490-6996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5050 N CLINTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825-5822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-484-8551
Provider Business Practice Location Address Fax Number:
260-482-5060
Provider Enumeration Date:
01/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HATHAWAY
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CREDENTIALING OFFICER
Authorized Official Telephone Number:
260-408-2203

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100054960 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100274410 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 490001781 . This is a "RAIL RAOD MEDICARE SURG" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: CI5112 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: CC5427 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: CK0104 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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