Provider Demographics
NPI:1437362076
Name:DIVERIS ORTHOPEDICS AND SPORTS MEDICINE,PC
Entity Type:Organization
Organization Name:DIVERIS ORTHOPEDICS AND SPORTS MEDICINE,PC
Other - Org Name:KDM PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIVERIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-263-8849
Mailing Address - Street 1:2562 WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46582-6522
Mailing Address - Country:US
Mailing Address - Phone:219-263-8849
Mailing Address - Fax:574-267-2866
Practice Address - Street 1:2562 WALTON BLVD
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46582-6522
Practice Address - Country:US
Practice Address - Phone:219-263-8849
Practice Address - Fax:219-476-0108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040065A207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN233950Medicare ID - Type Unspecified