1720393861 NPI number — FORT WAYNE ORTHOPEDICS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720393861 NPI number — FORT WAYNE ORTHOPEDICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT WAYNE ORTHOPEDICS, 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:
6
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:
1720393861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2021
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:
260-432-5075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 S MAIN STREET
Provider Second Line Business Practice Location Address:
STE 404A
Provider Business Practice Location Address City Name:
BLUFFTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46714-2503
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:
08/13/2010

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , 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: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • 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: 213ES0131X , 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: 332B00000X , 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: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 50002482 , 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: 201255250D , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100210470 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0162610005 . This is a "DME PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100210470A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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