Provider Demographics
NPI:1336109867
Name:ORTHOPAEDICS NORTHEAST, PC
Entity Type:Organization
Organization Name:ORTHOPAEDICS NORTHEAST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSISTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-484-8551
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:260-484-9603
Practice Address - Street 1:805 HIGH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-2324
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:260-484-9603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50001907A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN058940Medicare ID - Type Unspecified