Basic Information
| Provider Information | |||||||||
| NPI: | 1144215096 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONAL EMERGENCY PHYSICIANS PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PROFESSIONAL EMERGENCY PHYSICIANS INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3640 NEW VISION DRIVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604824440 | ||||||||
| FaxNumber: | 2604824442 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 RANDALLIA DRIVE | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603734000 | ||||||||
| FaxNumber: | 2604824442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 07/22/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GUTWEIN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2604824440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207P00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0882335 | 05 | OH | MEDICAID | 100050250C | 05 | IN | MEDICAID | 000000101129 | 01 | IN | ANTHEM | OTHER | 047840 | 01 | IN | MEDICARE CMS | OTHER | 100050250 I | 05 | IN | MEDICAID | 100050250 J | 05 | IN | MEDICAID | 100050250D | 05 | IN | MEDICAID | 100050250A | 05 | IN | MEDICAID | 100050250F | 05 | IN | MEDICAID | 100050250 H | 05 | IN | MEDICAID | 100050250E | 05 | IN | MEDICAID |