Basic Information
| Provider Information | |||||||||
| NPI: | 1780970251 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALTES | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR BLDG B | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602666013 | ||||||||
| FaxNumber: | 2604585831 | ||||||||
| Practice Location | |||||||||
| Address1: | 11123 PARKVIEW PLAZA DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604256650 | ||||||||
| FaxNumber: | 2604256649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2011 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | 01076052A | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 201331690 | 05 | IN | MEDICAID |