Basic Information
| Provider Information | |||||||||
| NPI: | 1265870588 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KINNE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 HICKMAN RD | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503141505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152825640 | ||||||||
| FaxNumber: | 5152822332 | ||||||||
| Practice Location | |||||||||
| Address1: | 7201 ENGLE RD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468042228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604321800 | ||||||||
| FaxNumber: | 2604321804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2013 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 01081602A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 207Q00000X | R-9785 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 300022826 | 05 | IN | MEDICAID | 249490007 | 01 | IN | MEDICAID | OTHER |