Provider Demographics
NPI:1003807850
Name:NORTHEAST MEDICAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:NORTHEAST MEDICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-480-2600
Mailing Address - Street 1:1234 E. DUPONT RD.
Mailing Address - Street 2:SUITE 6
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-480-2600
Mailing Address - Fax:260-496-8077
Practice Address - Street 1:1234 E. DUPONT RD.
Practice Address - Street 2:SUITE 6
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1545
Practice Address - Country:US
Practice Address - Phone:260-480-2600
Practice Address - Fax:260-496-8077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50004246A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1003807850OtherGROUP NPI
IN7795314OtherAETNA PIN
IN200335790AMedicaid
INCJ8803OtherMEDICARE RR
IN200335790AMedicaid