Basic Information
| Provider Information | |||||||||
| NPI: | 1619952280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASE | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | I. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SPARKS | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | I. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR | ||||||||
| Address2: | STE B | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602668210 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3909 NEW VISION DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604696610 | ||||||||
| FaxNumber: | 2609693065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 06/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01059698A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000346262 | 01 | IN | ANTHEM | OTHER | 3937240008 | 01 | IN | MEDICARE DMEPOS | OTHER | 4282045 | 01 | AETNA | OTHER | P00187398 | 01 | IN | RAILROAD MEDICARE | OTHER | 200499120 | 05 | IN | MEDICAID | 000000570552 | 01 | IN | ANTHEM | OTHER | 15709 | 01 | IN | PHYSICIANS HEALTH PLAN | OTHER |