1497758429 NPI number — FORT WAYNE ORTHOPAEDICS LLC

Table of content: (NPI 1497758429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497758429 NPI number — FORT WAYNE ORTHOPAEDICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT WAYNE ORTHOPAEDICS LLC
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:
Provider Other Organization Name Type Code:
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:
1497758429
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2526
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:
46801-2526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-436-8686
Provider Business Mailing Address Fax Number:
260-436-8585

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7601 W JEFFERSON BLVD
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:
46804-4133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-436-8686
Provider Business Practice Location Address Fax Number:
260-436-8585
Provider Enumeration Date:
05/23/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
JERALD
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
260-436-8686

Provider Taxonomy Codes

  • Taxonomy code: 207XS0106X , with the licence number:  50002482 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0117X , with the licence number: 50002482 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: 50002482 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0801X , with the licence number: 50002482 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: 50002482 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 50002482A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 50002482A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 50002482A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 201255250 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".