Basic Information
| Provider Information | |||||||||
| NPI: | 1790767085 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOLTYNIAK | ||||||||
| FirstName: | MIROSLAW | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E. DUPONT RD. | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 213 FAIRVIEW BLVD | ||||||||
| Address2: | |||||||||
| City: | KENDALLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467552988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603474900 | ||||||||
| FaxNumber: | 2603474966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 03/20/2013 | ||||||||
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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 | 208600000X | 01038834 | IN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100190980 | 05 | IN | MEDICAID | P00717118 | 01 | IN | MEDICAIRE RAILROAD | OTHER | 000000605424 | 01 | IN | ANTHEM | OTHER |