Provider Demographics
NPI:1346380847
Name:MICHAEL J PHEND, MD
Entity Type:Organization
Organization Name:MICHAEL J PHEND, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PHEND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-482-1681
Mailing Address - Street 1:6728 SWEET WOOD CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8127
Mailing Address - Country:US
Mailing Address - Phone:260-482-1681
Mailing Address - Fax:260-482-1857
Practice Address - Street 1:3124 E STATE BLVD
Practice Address - Street 2:SUITE 3F
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4798
Practice Address - Country:US
Practice Address - Phone:260-482-1681
Practice Address - Fax:260-482-1857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030254207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN133160Medicare ID - Type Unspecified
INB28633Medicare UPIN