Provider Demographics
NPI:1144215096
Name:PROFESSIONAL EMERGENCY PHYSICIANS PC
Entity Type:Organization
Organization Name:PROFESSIONAL EMERGENCY PHYSICIANS PC
Other - Org Name:PROFESSIONAL EMERGENCY PHYSICIANS INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:GUTWEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-482-4440
Mailing Address - Street 1:3640 NEW VISION DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1717
Mailing Address - Country:US
Mailing Address - Phone:260-482-4440
Mailing Address - Fax:260-482-4442
Practice Address - Street 1:2200 RANDALLIA DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:260-373-4000
Practice Address - Fax:260-482-4442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0882335Medicaid
IN100050250CMedicaid
IN000000101129OtherANTHEM
IN047840OtherMEDICARE CMS
IN100050250 IMedicaid
IN100050250 JMedicaid
IN100050250DMedicaid
IN100050250AMedicaid
IN100050250FMedicaid
IN100050250 HMedicaid
IN100050250EMedicaid