Basic Information
Provider Information | |||||||||
NPI: | 1912998014 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHEAST INDIANA COLON RECTAL SURGEONS PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11141 PARKVIEW PLAZA DR | ||||||||
Address2: | SUITE 310 | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468451701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604898898 | ||||||||
FaxNumber: | 2603734695 | ||||||||
Practice Location | |||||||||
Address1: | 11141 PARKVIEW PLAZA DR | ||||||||
Address2: | SUITE 310 | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468451701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604898898 | ||||||||
FaxNumber: | 2603734695 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/31/2005 | ||||||||
LastUpdateDate: | 02/28/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAIMAN | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PRACTITIONER | ||||||||
AuthorizedOfficialTelephone: | 2604898898 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | 50004032A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 2053852 | 05 | OH |   | MEDICAID |