Provider Demographics
NPI:1083833297
Name:FORT WAYNE PHYSICAL MEDICINE P C
Entity Type:Organization
Organization Name:FORT WAYNE PHYSICAL MEDICINE P C
Other - Org Name:FORT WAYNE PHYSICAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:V
Authorized Official - Last Name:REECER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-436-9337
Mailing Address - Street 1:5750 COVENTRY LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7166
Mailing Address - Country:US
Mailing Address - Phone:260-436-9337
Mailing Address - Fax:260-436-9626
Practice Address - Street 1:5750 COVENTRY LN
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7166
Practice Address - Country:US
Practice Address - Phone:260-436-9337
Practice Address - Fax:260-436-9626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4410190001Medicare NSC