Provider Demographics
NPI:1245213263
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/OWNER
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 1:3898 NEW VISION DR STE B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1719
Mailing Address - Country:US
Mailing Address - Phone:260-459-7313
Mailing Address - Fax:260-436-0628
Practice Address - Street 1:3898 NEW VISION DR STE B
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1719
Practice Address - Country:US
Practice Address - Phone:260-459-7313
Practice Address - Fax:260-436-0628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208100000X, 208VP0014X, 2251X0800X, 332B00000X, 363A00000X
IN10001306A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCI9946OtherRAILROAD MEDICARE
IN1281330001Medicare PIN
IN669740Medicare PIN