Provider Demographics
NPI:1194027946
Name:ORTHOPAEDICS NORTHEAST PC
Entity Type:Organization
Organization Name:ORTHOPAEDICS NORTHEAST PC
Other - Org Name:SURGERY ONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:HATHAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-490-6970
Mailing Address - Street 1:5050 N CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5822
Mailing Address - Country:US
Mailing Address - Phone:260-484-8551
Mailing Address - Fax:260-490-6996
Practice Address - Street 1:11420 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1729
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:260-490-6996
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORTHOPAEDICS NORTHEAST PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0217440002Medicare NSC
IN0217440002Medicare PIN