Basic Information
| Provider Information | |||||||||
| NPI: | 1255322244 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST INDIANA COLON RECTAL SURGEONS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7910 W JEFFERSON BLVD | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604898898 | ||||||||
| FaxNumber: | 2603734695 | ||||||||
| Practice Location | |||||||||
| Address1: | 7910 W JEFFERSON BLVD | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604898898 | ||||||||
| FaxNumber: | 2603734695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RAIMAN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 2604898898 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
No ID Information.