Provider Demographics
NPI:1619920295
Name:NORTHEAST INDIANA UROLOGY, PC
Entity Type:Organization
Organization Name:NORTHEAST INDIANA UROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRINKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-436-6667
Mailing Address - Street 1:2512 E DUPONT RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1609
Mailing Address - Country:US
Mailing Address - Phone:260-436-6667
Mailing Address - Fax:260-469-7437
Practice Address - Street 1:2512 E DUPONT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1609
Practice Address - Country:US
Practice Address - Phone:260-436-6667
Practice Address - Fax:260-469-7437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0748972Medicaid
IN100081380Medicaid
IN100081380Medicaid
INCB9217Medicare PIN
FLK9096Medicare PIN
FLDE4202Medicare PIN
IN136140Medicare PIN