Provider Demographics
NPI:1437263944
Name:CRISMAN, TED J (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:J
Last Name:CRISMAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:MEDPARTNERS, ATTN: MEGAN FORTNEY
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3515
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:401 S BROAD ST
Practice Address - Street 2:STE. B
Practice Address - City:FREMONT
Practice Address - State:IN
Practice Address - Zip Code:46737-2114
Practice Address - Country:US
Practice Address - Phone:260-495-9803
Practice Address - Fax:260-495-1238
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2017-01-17
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Provider Licenses
StateLicense IDTaxonomies
IN01030303A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100225590Medicaid
OH3117175Medicaid
IN000000329797OtherANTHEM BCBS OF INDIANA
4048082OtherAETNA
IN000000329797OtherANTHEM BCBS OF INDIANA
B29445Medicare UPIN
OH3117175Medicaid