Provider Demographics
NPI:1154304186
Name:SPINE TECHNOLOGY AND REHABILITATION, P.C.
Entity Type:Organization
Organization Name:SPINE TECHNOLOGY AND REHABILITATION, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:D
Authorized Official - Last Name:FORTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:260-459-7313
Mailing Address - Street 1:909 W MAUMEE ST
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-1368
Mailing Address - Country:US
Mailing Address - Phone:260-459-7313
Mailing Address - Fax:
Practice Address - Street 1:909 W MAUMEE ST
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-1368
Practice Address - Country:US
Practice Address - Phone:260-459-7313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN192720Medicare ID - Type Unspecified