Basic Information
| Provider Information | |||||||||
| NPI: | 1063460160 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INSTITUTE FOR ORTHOPEDIC AND NERVE SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 230 E DAY RD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742474667 | ||||||||
| FaxNumber: | 5742714458 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 E DAY RD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465453408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742474667 | ||||||||
| FaxNumber: | 5742714458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 02/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | AKRE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | GERARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5742474667 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 02002335A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200335260A | 05 | IN | MEDICAID |