Basic Information
Provider Information | |||||||||
NPI: | 1114919131 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAIMAN | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1234 E DUPONT RD | ||||||||
Address2: | SUITE 1 | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468251545 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2603739700 | ||||||||
FaxNumber: | 2603739740 | ||||||||
Practice Location | |||||||||
Address1: | 11141 PARKVIEW PLAZA DR | ||||||||
Address2: | SUITE 310 | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468451701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604898898 | ||||||||
FaxNumber: | 2603734695 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/16/2005 | ||||||||
LastUpdateDate: | 03/23/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | 01034793A | IN | Y |   | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 000000614766 | 01 | IN | ANTHEM | OTHER | 020037713 | 01 | IN | RR MEDICARE | OTHER | 100096150 | 05 | IN |   | MEDICAID | 100096150A | 05 | IN |   | MEDICAID | 000000595629 | 01 | IN | ANTHEM | OTHER | 0610888 | 05 | OH |   | MEDICAID |