Basic Information
| Provider Information | |||||||||
| NPI: | 1740257914 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEWSWANGER | ||||||||
| FirstName: | R | ||||||||
| MiddleName: | BRUCE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 419569 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022419569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812801699 | ||||||||
| FaxNumber: | 7812766454 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 EAST BLVD | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465142483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745233160 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 11/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 02001536 | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 200331530 | 05 | IN | MEDICAID | 000000082207 | 01 | IN | ANTHEM | OTHER | 113067774 | 05 | MI | MEDICAID | 930017086 | 01 | IN | RAIL ROAD MEDICARE | OTHER |