Provider Demographics
NPI:1144212077
Name:KAISER, ADAM R (MD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:R
Last Name:KAISER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10021 DUPONT CIRCLE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1604
Mailing Address - Country:US
Mailing Address - Phone:260-426-8117
Mailing Address - Fax:260-420-0817
Practice Address - Street 1:10021 DUPONT CIRCLE CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1604
Practice Address - Country:US
Practice Address - Phone:260-426-8117
Practice Address - Fax:260-420-0817
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060268A207Y00000X
IN35-087163207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200519040Medicaid
OH2548630Medicaid
OHKA4180131Medicare PIN
OH2548630Medicaid
INP00233764Medicare PIN
IN200519040Medicaid
ININ1333041Medicare PIN
IN047930QMedicare PIN